State of the Art in Cardiac Intervention: A Case Report

The first acute myocardial infarction (MI) of an elderly male was determined through angiography to be due to an infarct of the circumflex artery. The angiogram also revealed chronic occlusion and diffuse disease of the left anterior descending artery (LAD). This had been compensated for by collateral circulation from the right coronary artery. Since the patient had no prior history of coronary artery disease, the chronic and collateralized disease of the LAD was presumed to be stable and this artery was not treated. Due to a history of aspirin intolerance a bare metal stent was implanted in the circumflex artery. Within hours after stenting the patient had a second acute MI. Despite no change in the angiogram, the EKG suggested that the LAD was the source of the second MI. Indeed, a drug-eluting stent implanted in the LAD resolved the patient’s signs and symptoms and he was discharged with a favorable outcome. The surprising second MI and the inconsistent stenting illustrate that when the unexpected occurs, there is no substitute for the judgment of a skilled clinician.