Searching for the Culprit Vessel in Acute Myocardial Infarction Beyond Angiography

An 80-year-old hypertensive man with previous percutaneous coronary interventions with stent implantation on the right and left circumflex coronary arteries was referred to our center because of ST-segment elevation anterior myocardial infarction. At admission the ECG showed a right bundle-branch block and ST-segment elevation in V1 through V4, III, and aVF. Akinesis in the middle and distal interventricular septum with preserved left ventricular systolic function was showed by transthoracic echocardiography. No images suggestive of aortic dissection were visualized. Emergent coronary angiography revealed a moderate lesion in the mid-left anterior descending coronary artery with good anterograde coronary flow (Figure 1A). The stents on the right and left circumflex coronary arteries showed no significant stenoses and a normal coronary flow. Although the patient reported persistent chest pain and the ECG remained unchanged, no coronary revascularization was attempted as the culprit lesion could not be identified. Clinical outcome was characterized by an important rise in cardiac biomarkers that showed an early peak (high-sensitivity troponin T 2624 ng/mL [normal value, 0–14 ng/mL]; creatin-kinase 1107 IU/L [normal value, 7–177 IU/L], and MB fraction 123 IU/L). To further ascertain …