Inferior Wall Myocardial Infarction Research Articles

Echocardiographic assessment of right ventricular function in inferior wallmyocardial infarction and angiographic correlation with right coronary artery disease

Echocardiographic assessment of right ventricular function in inferior wallmyocardial infarction and angiographic correlation with right coronary artery disease

Study of right ventricular global longitudinal strain imaging in patients of acute inferior wall myocardial infarction and its correlation with in hospital outcome

Study of right ventricular global longitudinal strain imaging in patients of acute inferior wall myocardial infarction and its correlation with in hospital outcome

Dead man sign of ECG: An unique predicting sign of acute coronary syndrome

Coronary artery disease is the most common cause of morbidity and mortality worldwide. Acute coronary syndrome which includes STEMI, NSTEMI and unstable angina commonly diagnosed with the help of 12 lead in ECG in ER with or without elevated biomarkers. Inferior wall myocardial infarction is common cause of ST elevation myocardial infarction with low mortality rate. In this case report, we present a 52 years old male presented to ER with the complain of typical chest pain for more than 2 hours duration. Pain was in center of chest with radiation to back and left arm and associated with excessive sweating. Patient is a known smoker for past 10 years. At presentation Blood pressure was 110/70 mmHg and pulse rate of 55/min. Troponin I level was five times of upper normal limit. Basic investigations including ECG were done at presentation. ECG was showing typical changes of inferior wall myocardial infarction with infarction of right ventricle with hidden unique sign known as dead man sign commonly predict the location of obstruction and course of disease in the setting of acute coronary syndrome.

Abstract 9449: Extracorporeal Membrane Oxygenation versus Impella in Patients with Cardiogenic Shock from Inferior Wall Myocardial Infarction: Analysis from the National Inpatient Sample

Introduction: Since the IABP-SHOCK II trial, extracorporeal membrane oxygenation (ECMO), and the percutaneous ventricular assist device, Impella have emerged as the preferred mechanical circulatory assist devices for cardiogenic shock (CS). Studies have shown similar clinical outcomes with Impella and ECMO in patients with CS from unspecified myocardial infarction (MI) locations; however, data in patients with inferior wall MI is lacking. Hypothesis: ECMO is associated with an increased likelihood of adverse inpatient complications and medical costs compared to Impella in patients with CS from an inferior wall MI. Methods: We queried the National Inpatient Sample (NIS) from 2016-2018 to identify patients 18 years and older with a discharge diagnosis of CS from inferior wall MI who underwent ECMO or Impella placement. To mitigate selection bias, 8-to-1 propensity scoring was used to select matched samples between patients with ECMO and patients with Impella. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, income, and medical comorbidities. Results: We identified 638 patients with inferior wall MI resulting in CS, 15% (n=96) underwent ECMO and 85% (n=542) received Impella. ECMO was not associated with increased inpatient mortality (52% vs 50.7%; p=0.86) or cardiac arrest (24% vs 15%, p=0.09) when compared to Impella. After applying the multivariate logistic regression model, ECMO was not associated with an increased risk for acute kidney injury (OR 0.67; 95% CI 0.28-1.6, p=0.36), cerebrovascular events (OR 1.06; 95% CI 0.33-3.36, p=0.92), cardiac tamponade (OR 6.85; 95% CI 0.89-52.83, p=0.06) or CPR (OR 1.89; 95% CI 0.9-3.98; p=0.09). However, ECMO was associated with increased blood transfusions (OR 3.56; 95% CI 0.26-10.06, p=0.02), increased length of hospitalization (13.2 days vs 9.4 days; p<0.0001), and medical costs ($501,435 vs 403,120, p<0.0001). Conclusions: Our study demonstrates that ECMO is not associated with increased mortality in patients with CS from inferior wall MI compared to Impella, although Impella remains the more cost-effective choice in these patients. Future randomized studies are warranted comparing these circulatory assist devices in patients with CS.

Clinical profile of ST-elevation myocardial infarction patients from a tertiary care hospital in Northern India

Background: Our aim was to the study clinical and epidemiological profile of patients presenting with ST-elevation myocardial infarction (STEMI).Methods: We did a single centre cross-sectional observational study of 200 patients presented with STEMI to a tertiary referral centre in Northern India from January 2016 to November 2017. All patients above 18 years of age admitted with diagnosis of STEMI were included in the study.Results: The mean age of study population was 55.75±12.5. The most common chief compliant was chest pain (95.1%). The anterior wall myocardial infarction (AWMI) accounted for 60.5% of all STEMI patients. The median duration from onset of symptoms to presentation to hospital was 7.93±6.58 hours. Cardiogenic shock was observed in 10.5% patients. Most common risk factor noted was smoking (63%). Mean left ventricular ejection fraction (LVEF) was less in AWMI (47±9.09) as compared to inferior wall myocardial infarction (IWMI) (50.72±7.14) (p<0.05). Among 200 cases studied, 11.5% cases developed post MI-Angina. Among arrhythmic complications, sinus bradycardia was most common (17.5%).Conclusions: Our study represents the predominance of AWMI as the initial acute coronary syndrome (ACS) presentation with a considerable delay in first medical contact. Complications like cardiogenic shock, arrhythmia were frequently observed. The biggest barrier to uniform STEMI care in developing nations is nonexistence of regional systems of care and this need to be improved.

Assessment of right ventricular function in patients presenting with inferior ST segment elevation myocardial infarction and right ventricular infarction undergoing primary percutaneous intervention by different echocardiographic modalities in correlation with angiographic findings

Abstract Background Patients with inferior wall myocardial infarction who have right ventricular (RV) involvement appear to have a worse prognosis than those without RV involvement; infarcted RV tissue fails to offer a sufficient preload which is essential for adequate LV performance. Thus, assessment of RV function is an important step in dealing with patients presenting with inferior wall myocardial infarction that will help in adopting a proper management plan. Objective To assess the correlation between RV function and angiographic findings in patients presenting with inferior wall myocardial infarction associated with RV infarction undergoing primary percutaneous coronary intervention. Patients and Methods Study included 60 patients who presented to Ain shams university hospitals by inferior wall ST segment elevation myocardial infarction associated with RV infarction during the period from February 2019 to August 2019.All patients were subjected to history taking, clinical examination, ECG recording then primary percutaneous coronary intervention. Echocardiographic assessment was done to all patients within 48 hours of admission. Results Study included 60 patients, 43 males (71.7%) and 17 females (28.3%), with mean age of 56.73 ± 9.94 years. Commonest Infarction related Artery (IRA) associated with impaired RV function was proximal RCA (p-value: 0.003). In 23 patients (38.3%) heavy thrombus burden was found while in the other 37 patients (61.7%) there was no evidence of heavy thrombus burden. Regarding post procedural TIMI flow grade: 1 patient (1.7%) had final TIMI I flow, 9 patients (15.0%) had final TIMI II flow and 50 patients (83.3%) had final TIMI III flow. There was statistically significant relationship between RV function assessed through measuring RV free wall strain and both of thrombus burden and final TIMI flow grade. Abnormal RV function was more commonly associated with heavy thrombus burden (p-value:0.023) and less than TIMI III flow after angioplasty (p-value:0.011).RV free wall systolic strain assessment had highest accuracy (75%) in detection of proximal RCA occlusion compared to other parameters including TAPSE, S’ and FAC. Conclusion Impaired RV function in patients presenting with RV infarction can be predicted by different angiographic findings. Proximal RCA total occlusion being commonest IRA associated with impaired RV function. Also, presence of heavy thrombus burden and less than TIMI III flow after angioplasty are associated with increased risk of impaired RV function. RV free wall strain measured by 2D-speckle tracking echocardiography has highest accuracy in detection of proximal RCA occlusion compared to other echocardiographic indices including TAPSE, S’ and FAC.

Multiple Linear Filling Defects in Coronary Artery: Differential Diagnosis

Abstract A 60-year-old male, diabetic, nonhypertensive, tobacco chewer, presented with a history of inferior wall myocardial infarction in 2007. Patient underwent percutaneous transluminal coronary angioplasty with stent to right coronary artery in 2007, but no reports available. Now, patient was admitted with new onset crescendo angina for the last 1 month.

Anomalous Origin of Left Main Coronary Artery from Right Coronary Artery in A Patient Presenting with Inferior Wall Myocardial Infarction: A Case Report

Anomalous origin of the coronary arteries is a very rare phenomenon and is seen only in less than 1% of the general population. Single coronary artery (SCA) is a congenital anatomic abnormality identified by a single coronary ostium giving rise to one coronary artery. Our case presented at 40 years with intermittent chest discomfort, effort intolerance and a history of getting Streptokinase one month back due to AMI (Inferior). Diagnosis was confirmed with elective conventional coronary angiography and coronary CT angiography as an extremely rare variant of the left main coronary artery (LMCA) branching off from the right coronary artery (RCA) and then following a pre-pulmonic course. We did Off Pump CABG surgery with four grafts and discharged the patient uneventfully with guidelinedirected medical therapy with a beta-blocker, statin, and dual antiplatelet agents and the patient is on follow up. Bangladesh Heart Journal 2021; 36(1) : 61-66

Acquired Hemophilia in Association With Pemphigus Vulgaris: An Uncommon Coexistence: A Case Report

Acquired Hemophilia (AHA) is a relatively rare disease that occurs in patients with no previous family history of hemophilia. The spontaneous development of autoantibodies (IgG1 and IgG4) against factor VIII has been reported as the most probable cause of AHA. AHA has been reported in association with other conditions, including some autoimmune bullous skin diseases, such as bullous pemphigoid, pemphigus vulgaris, and pemphigus foliaceous. To the best of our knowledge, only 21 cases of AHA with skin autoimmune bullous diseases have been reported so far. Herein, we report a 63-year-old male with a previous history of pemphigus vulgaris who developed large ecchymotic areas on his lower abdomen and forearms after the second infusion of rituximab. Based on coagulation factors evaluation, he was diagnosed with AHA. Treatment with factor VII led to the improvement in his coagulation status, but unfortunately, he passed away because of inferior wall myocardial infarction four days later.

Ventricular septal rupture with septal aneurysm complicating acute inferior wall myocardial infarction treated surgically—a case report

Ventricular septal rupture with septal aneurysm complicating acute inferior wall myocardial infarction treated surgically—a case report

English

BACKGROUND A significant number of patients with acute Inferior wall infarction will have RV dysfunction and most of them have occlusion of either right or left circumflex coronary artery. But RV assessment is not done routinely in echocardiographic examination. Patients present with inferior wall myocardial infarction (IWMI) subsequently develop right ventricular myocardial infarction (RVMI) and have poor prognosis. In this study we wanted to evaluate the incidence of RVMI and the role of echocardiography in assessing RV function and its impact in predicting infarct related artery by angiographic analysis in acute IWMI after thrombolysis. METHODS 86 patients with acute IWMI after thrombolysis were randomly selected. Echocardiographic examination of RV function was performed within 72 hours after thrombolysis. We applied RV echo parameters like FAC (Fractional Area Change %), TAPSE (Tricuspid Annular Plane Systolic Excursion), RV S’ (RV Systolic Excursion Velocity) and MPI (Myocardial Performance Index) to assess RV function. 48 patients underwent coronary angiogram which included 10 patients with normal RV function, rest with RV dysfunction. RESULTS Among 86 patients, we compared 64 patients of RV dysfunction with 22 patients having normal function. Echo indices were significantly lower in RV dysfunction group. FAC ( 27 ± 5.95 vs 45 ± 5.4 ) TAPSE (8.5 ± 2.0 19.59 ± 2.8 ), RV S’ ( 5.78 ± 1.26 vs 17.2 ± 3.5 ) and RVMPI (0.22 ± 0.03 vs 0.57± 0.03). Angiographic analysis of 28 of 38 patients with RV dysfunction showed significant proximal lesion in RCA as compared to only 2 among 10 patients with normal RV function. CONCLUSIONS Conventional echo examination will underestimate RV dysfunction hence we applied echo parameters like FAC, TAPSE, RV S’ and RVMPI and a significant proportion of thrombolysed acute IWMI patients were found to have RV dysfunction and it was also helpful in the prediction of infarct related artery which would be predominantly a critical proximal RCA occlusion. KEY WORDS RVMI (Right Ventricular Myocardial Infarction), FAC (Fractional Area Change %), TAPSE (Tricuspid Annular Plane Systolic Excursion), RV S’ (RV Systolic Excursion Velocity) ,MPI (Myocardial Performance Index), IRA ( Infarct Related Artery)

Hyponatremia as a prognostic indicator in acute myocardial infarction

Background: Every year, myocardial infarction causes more deaths and disabilities than any other disease in the world, and In fact, it is the most prevalent form of a life-threatening chronic illness.Objectives: To study hyponatremia as a prognostic indicator in acute myocardial infarctionMethods: 100 patients with Acute Myocardial Infarction who were admitted to the ICU and the Department of Internal Medicine. All patients had a 12-lead ECG, with the right sided and posterior leads taken for inferior wall MI. A detailed history was collected, as well as a detailed clinical examination, as well as daily serum electrolytes and ECHO was done. An Ion selective electrode auto analyzer was used to determine the serum sodium concentration (Roche OMNIC).Results: In our study 64% were males and 36% were females. Males are more prone for ischemic heart diseases. The proportion of Diabetic, Smokers, hypertensives were more among patients with Hyponatremia. anterior wall MI was the most prevalent, followed by inferior wall MI. Killip class I is found in 74% of patients with normal sodium levels compared to 58% in hyponatremia groups, class II in 20% of patients compared to 24% in hyponatremia, class III in 6% of patients compared to 16% of hyponatremia patients, and class IV in 2% of hyponatremia patients whose sodium level was 130 or lower. Patients who developed hyponatremia had a greater mortality rate than those who had normal sodium levels.Conclusion: Asians are more likely to develop STEMI. The severe the Hyponatremia, the poorer the prognosis. Hyponatremia and a reduced ejection fraction are more common in anterior wall MI patients than those with normal sodium levels.

Antiplatelet Agents Utilization Pattern and Assessment of Patient Specific Drug use Problems among Cardiac Patient

Background: Antiplatelet agents reduce the occurrence of the cardiovascular issue in people with established cardiovascular disease.
 Objective: To understand the pattern of Antiplatelet drug utilization among cardiovascular disease patients. To evaluate the prevalence of polypharmacy and responsible factors like age, gender, co-morbid condition, and patient-related drug use problems.
 Methodology: A cross-sectional observational study. Patients with cardiovascular disease above 18 years of age were prescribed antiplatelet agents from the department of cardiology and ICCU were enrolled in the study.
 Result: A total of 150 patients were enrolled of which male 79% (N=119) and female 21% (N=31). Most patients belong to 51-60 years of age groups. The patients diagnosed with IWMI (inferior wall myocardial infarction) 43.3% (N=65) have highly prescribed antiplatelet agents. Smoking 54.7% (N=82) followed by Alcohol 26.7% (N=40) found to be the most dominant risk factors.60.7% (N=91) patients had no comorbidity followed by 31.3% (N=47) had a comorbid cardiac condition. Most prescribed antiplatelet agents were monotherapy of Aspirin 28.8% (N=43), Clopidogrel 16.7% (N=25), and combination therapy of both 51.2% (N=82).
 Conclusion: The study concluded that increases in the number of co-morbidities can significantly increase the Utilization of drugs which can further lead to drug use problems. The clinical pharmacist can help to alleviate the problems of polypharmacy and its consequence.

Role of 2-dimensional speckle tracking echocardiography in diagnosis of right ventricular involvement in patients with inferior wall myocardial infarction undergoing primary percutaneous coronary intervention.

Diagnosis of right ventricular (RV) infarction in the setting of acute inferior wall myocardial infarction (IWMI) has important prognostic implications. We sought to assess the role of 2-D speckle tracking echocardiography (2-D STE) for the assessment of RV involvement in acute IWMI.We included 100 consecutive patients with a diagnosis of recent IWMI, of which 73 had an RCA culprit lesion, undergoing primary percutaneous coronary intervention (PPCI). Patients (n = 73) were classified into 2 groups based on angiographic evidence of RV involvement (lesions proximal to or involving RV branch versus distal lesions). Echocardiographic features of RV dysfunction were assessed using conventional 2-D echocardiographic, and Tissue Doppler parameters as well as 2-D speckle tracking echocardiography.Out of the 73 patients, 42 had RCA lesion proximal to or involving RV branch, while 31 patients had RCA culprit distal to RV branch. Among different parameters assessing RV function, only RV-FWLS was significantly lower among the former group (- 14.2 ± 4.6 vs. - 17.7 ± 4.2, p = 0.026). Receiver-operator characteristic (ROC) analysis showed that RV-FWLS had the strongest discriminatory capability to identify RV infarction (AUC = 0.7, p = 0.02, 95% CI 0.53-0.78). A cut-off value of RV-FWLS ≤ - 20.5% had 88% sensitivity and 33% specificity for diagnosis of RV infarction.STE-derived RV-FWLS with cutoff ≤ - 20.5% could be a reliable and promising tool for prediction of RV involvement in the setting of acute IWMI, which could guide proper risk stratification and tailored acute management strategy.

Management of late onset recurrent ventricular tachycardia following circumflex artery injury during minimally invasive mitral valve replacement surgery – Clinical case report

Abstract Introduction: A rare complication of mitral valve surgery is the injury of the circumflex artery due to their close anatomical proximity resulting in a perioperative myocardial infarction and subsequent fibrosis with increased risk of developing ventricular arrhythmias. Case presentation: We hereby describe the case of a 74-year-old male patient who underwent minimally invasive mitral valve replacement surgery for severe mitral regurgitation two weeks prior to presenting to the emergency department with dyspnea, palpitations and slight thoracic discomfort. He was diagnosed with recurrent sustained monomorphic ventricular tachycardia due to inferior wall myocardial infarction. Angioplasty of the culprit lesion was attempted, but the procedure failed due to the elastic recoil of the vessel. Our patient received antiarrhythmic therapy and an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death, with no further recorded episodes of ventricular tachycardia. Conclusion: Although injury of the circumflex coronary artery during mitral valve surgery is described as rare, we strongly believe that increasing awareness of the potential risks involved can further prevent fatal complications.

Comparison of clinical outcome in acute inferior wall myocardial infarction based on culprit artery: right coronary artery vs left circumflex artery

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Acute inferior wall myocardial infarction (AIWMI) is related to Right Coronary Artery (RCA) occlusion in about 80% of cases and to Left Circumflex Artery (LCX) in the rest of them, in most series. However it has not been established yet if there is a difference in prognosis depending on culprit artery. PURPOSE This study compares clinical outcome during hospital stay between RCA-related and LCX-related AIWMI. METHODS We analysed all patients with AIWMI admitted to the Cardiac Care Unit between August 2011 and February 2019, both ST-elevation (STEMI) and non ST-elevation myocardial infarction, and whose culprit artery was either the RCA or the LCX. Basal characteristics and clinical outcome during hospital stay were compared between RCA and LCX. RESULTS Among 2252 patients with acute coronary syndrome, 650 were AIWMI. Among them, the culprit artery was the RCA in 461, the LCX in 149, and other or not defined in 30. The mean age was 61.7 ± 11.6 years, 79% of them were male and 21% female. They had a history of current smoking in 50.7%, diabetes mellitus in 24.4%, hypertension in 52.1%, dyslipemia in 44.3% and obesity in 28.7%, without differences between RCA and LCX. RCA patients presented as STEMI in 93.3% vs 87.2% of LCX patients (p = 0.025). Among those presenting as STEMI, 84.4% of RCA and 90.8% of LCX underwent primary coronary intervention. Mean ejection fraction was 50.8% in RCA and 51.2% in LCX. Three-vessel or left main disease was present in 10.2% of RCA and 10.8% of LCX. There was atrioventricular block in 17.8% of RCA and 3.4% of LCX (p < 0.001); atrial fibrillation in 10.2% of RCA and 11.4% of LCX, ventricular fibrillation in 10.4% of RCA and 7.4% of LCX. Median of peak CPK was 1203 in RCA, vs 1785 in LCX (p < 0.001). There was cardiogenic shock (CS) at admission in 5.4% of RCA vs 1.3% of LCX, (p = 0.038) and CS whenever the hospital stay in 8.4% vs 4.0% (p = 0.072). In-hospital mortality was 3.3% in RCA and 3.4% in LCX. Several models of multivariate logistic regression analysis did not find a predictive value of the culprit artery in the development of CS or in-hospital mortality. CONCLUSION AIWMI related to LCX have greater enzymatic size than those related to RCA. However, RCA infarctions present more often atrioventricular block and cardiogenic shock at admission. Multivariate analysis did not shock significant differences in the development of CS or in-hospital mortality. Abstract Figure. Peak CPK depending on culprit artery

Inter-Rater Reliability of ST-Segment Measurement at a University Hospital in Argentina

The accurate determination of the electrocardiographic ST-segment elevation in a patient with clinical suspicion of acute coronary syndrome is essential for treatment with urgent myocardial reperfusion. The aim of this study was to determine the inter-rater reliability of ischemic and non-ischemic ST-segment elevation measurement among physicians with different specialties and experience. We performed an observational, cross-sectional study, with a comparative correlation and paired sampling. 56 physicians from a university hospital in Buenos Aires city were included: Cardiologists from the Coronary Care Unit (CCU) and Cardiology Division, Internal Medicine physicians from the hospitalization, ambulatory care and Emergency divisions, and third- and fourth-year Internal Medicine residents. Each participant analyzed 6 electrocardiograms and was asked to determine the magnitude of the ST-segment elevation at the J-point, and the corresponding diagnosis. The inter-rater coefficient was lower than 0.2, and the global kappa coefficient was 0.06 (p < 0.001). The global correct interpretations were: inferior wall myocardial infarction (MI): 89.3%; anterior wall MI: 51.8%; lateral wall MI: 75%; left bundle branch block: 91.1%; left ventricle hypertrophy: 44.6%; acute pericarditis: 25%. We believe that the low correlation was probably due to the difficulty in determining the J-point. These findings could suggest the need to strengthen the electrocardiographic concepts of ischemia, and the differentiation between ischemic and non-ischemic ST-segment elevations.

Hypertrophic cardiomyopathy mimicking inferior wall myocardial infarction

Electrocardiogram is most often the first-hand diagnostic tool with a cardiologist. Promptly identifying life threatening arrhythmias and myocardial infarction with ECG saves many lives. Quite often the electrocardiogram may have dubious findings and further testing helps arriving at the right diagnosis. Herein, we present a case of hypertrophic cardiomyopathy where the ECG mimicked inferior wall myocardial infarction along with a raised high sensitive Troponin T (hsTnT). A coronary angiogram failed to reveal any acute or chronic obstructive lesion in the coronary arteries. We discussed the varied ECG patterns in hypertrophic cardiomyopathy and causes of troponin elevation apart from myocardial infarction. We also discussed other causes of ‘pseudo-infarct’ pattern on ECG. This provides insight into a more comprehensive approach in management of each patient.

Short and Long-Term Survival Rates Following Myocardial Infarction and Its Predictive Factors: A Study Using National Registry Data.

Background: Coronary artery disease is the most common cause of death worldwide as well as in Iran. The present study was designed to predict short and long-term survival rates after the first episode of myocardial infarction (MI). Methods: The current research is a retrospective cohort study. The data were collected from the Myocardial Infarction Registry of Iran in a 12-month period leading to March 20, 2014. The variables analyzed included smoking status, past medical history of chronic heart disease, hypertension, diabetes, hyperlipidemia, signs and symptoms during an attack, post-MI complications during hospitalization, the occurrence of arrhythmias, the location of MI, and the place of residence. Survival rates and predictive factors were estimated by the Kaplan–Meier method, the log-rank test, and the Cox model. Results: Totally, 21 181 patients with the first MI were studied. There were 15 328 men (72.4%), and the mean age of the study population was 62.10±13.42 years. During a 1-year period following MI, 2479 patients (11.7%) died. Overall, the survival rates at 28 days, 6 months, and 1 year were estimated to be 0.95 (95% CI: 0.95 to 0.96), 0.90 (95% CI: 0.90 to 0.91), and 0.88 (95% CI: 0.88 to 0.89). After the confounding factors were controlled, history of chronic heart disease (p<0.001), hypertension (p<0.001), and diabetes (p<0.001) had a significant relationship with an increased risk of death and history of hyperlipidemia (p<0.001) and inferior wall MI (p<0.001) had a significant relationship with a decreased risk of death. Conclusion: The results of this study provide evidence for health policy-makers and physicians on the link between MI and its predictive factors.

TCTAP C-002 Blend of Conventional and Nonconventional Approach During Primary PCI of a Daunting Acute Inferior Wall MI: A Short Story

TCTAP C-002 Blend of Conventional and Nonconventional Approach During Primary PCI of a Daunting Acute Inferior Wall MI: A Short Story