Double coronary artery occlusion presenting as inferior ST segment elevation myocardial infarction and Wellens...

ST elevation myocardial infarctions are usually a consequence of the occlusion of a single coronary artery, but in 2.5% of the cases, two or more culprit lesions are found. Simultaneous coronary artery occlusion is a potentially life-threatening condition that leads to cardiogenic shock or ventricular arrhythmias.

We presented the case of a 74-year-old man presenting with chest pain and ST segment elevation (STE) in inferior leads and evidence of alternating STE in anterior leads in a pattern like Wellens syndrome type A in subsequent electrocardiogram (ECGs). Emergency coronary angiography (CA) revealed thrombotic occlusion of the proximal right coronary artery (RCA) and sub-occlusion of mid left anterior descending artery (LAD). During the CA, he became haemodynamically unstable requiring intravenous inotropes and vasopressors, and he underwent primary percutaneous coronary intervention of both RCA and LAD culprit lesions. His subsequent hospital stay was uneventful, and he was discharged 5 days later.

ST elevation myocardial infarction with more than one culprit coronary artery is a rare but at high risk of haemodynamic decompensation. The causes of occlusion of multiple coronary arteries may be several: coronary embolism, coronary ectasia, simultaneous plaque disruption, coronary vasospasm, hypercoagulability states, smoking, and illicit drug abuse. The presumed mechanism behind the presented case may be a combination of release of pro-thrombotic cytokines due to the thrombotic occlusion of the first coronary and low output state secondary to myocardial dysfunction leading to impaired flow in a severe stenotic coronary artery with subsequent thrombosis.