When the Innocent Bystander Becomes the Culprit: Two Episodes of STElevation Myocardial Infarction with Different Culprit Coronary Arteries in A Single Patient Occurring Two Days a Part

Abstract

Background: Recurrent ST elevation myocardial infarction (STEMI) with different culprit lesions in a single patient occurring few days apart is uncommon with limited similar cases reported. Case Presentation: This is a case of a 53-year-old male who presented to the Emergency Department with left upper quadrant abdominal pain and an initial electrocardiogram showing ST elevation MI in the anterolateral leads. He underwent successful primary angioplasty of the culprit lesion (LAD) with placement of a single Everolimus drug-eluting stent with plans for staged intervention within a month of the remaining severe lesion in the left circumflex (LCx) artery (non-infarct related vessel). Two days after the initial STEMI, the patient experienced recurrence of abdominal pain with hypotension, and a repeat ECG revealed new ST segment elevation in the inferior leads. A repeat coronary angiogram demonstrated a widely patent stent in the LAD and the previously noted diseased LCx. No other new lesions were noted and the RCA was also patent. The patient then underwent a successful second primary PCI of the previously untreated severe lesion in the LCx. Conclusion: Consecutive episodes of acute myocardial infarction in different coronary arteries occurring within hours to a few days after primary PCI for STEMI is uncommon and can be catastrophic if not detected early. The mechanism and predisposing factors to such event are still unclear. The optimum interventional treatment strategy regarding the immediate management of STEMI in patients with multi-vessel disease remains controversial.