Associazione Nazionale Medici Cardiologi Ospedalieri



Double ST-elevation, double occlusion?

Ajmone Francesco Maria Roma(Roma) – Policlinico Umberto I | Mancone Massimo Roma(Roma) – Policlinico Umberto I | Sardella Gennaro Roma(Roma) – Policlinico Umberto I

CASE PRESENTATION: A 71-year-old woman was referred to our outpatient clinic for two episodes of chest pain during last two days. Her past medical history was remarkable for arterial hypertension, obesity, diabetes mellitus type 2 treated by oral hypoglycaemic agents complicated by diabetic maculopathy.

DIAGNOSTIC WORK-UP: At the presentation, the patient was symptomathic for chest pain, hemodynamically stable. The ECG showed synus rhythm, left-axis deviation, Q wave and ST-elevation from V2 to V5 and in DIII and ST-elevation in DII and aVF (FIGURE 1). Transthoracic echocardiography revealed concentric hypertrophy, mildly reduced LV ejection fraction (EF 45%) with akinesia of intreventricular septum and apex, without severe valvulopathies and no pericardial effusion. Given the clinical data the patient was addressed to urgent coronary angiography that showed LAD occlusion at the end of his proximal tract and right coronary artery occlusion at the beggining of his second tract (FIGURE 2); furthermore omo and etero-coronaric collaterals for right coronary artery area were detected . By using a workhorse guidewire flow was restored in both coronary arteries and PTCA was performed with 3 DES on LAD and other 2 DES on right coronary artery (FIGURE 3). The patient was transferred to our coronaric intensive unit care after the procedure; no complications were noticed during the hospitalization. A week after the patient was discharged in good general health.

CONCLUSION: Multiple simultaneous coronary occlusions are reported in literature, yet the accurate incidence and physiopathology of this occurrence is still uncertain. Probably the symphathetic system activation caused by first coronary occlusion could promote an increased basal platelets activation and then the second coronary occlusion. Our case shows that during coronary angiography identifying a culprit lesion may be delicate and cardiologists should be prepared to manage multiple coronary occlusions.