Double Culprits in a Patient with ST Elevation Myocardial Infarction: A Challenging But Rewarding Case.

Myocardial infarction simultaneously involving two or more culprit lesions is extremely rare and usually has a poor clinical outcomes including mortality. Management of this complicated condition is challenging and limited time. Nevertheless, autopsy studies revealed that thrombotic occlusion of more than one major epicardium coronary artery is not uncommon. A 68-year-old woman presented with sudden onset of limited breath and chest discomfort since two hours prior to admission. She also felt exert dyspnoea since one month ago. She has two risk factors that were uncontrolled that is hypertension (HT) and type 2 diabetes mellitus (DM). On admission, she succumbed into cardiogenic shock and pulmonary oedema. ECG revealed a diminished R wave in V2-V4 with ST elevation in V2-V5 and in aVR. Biphasic T wave was seen in V2-V6. The working diagnosis was anterior STEMI, Killip class IV with thrombolysis in Myocardial Infarction (TIMI) score of 8. While being transferred to catheter lab, she gasped, became desaturation, and was intubated prior to procedure. The patient was given double inotropes which run maximally. By Coronary angiography, there were occlusions at the LAD and LCX. Stent was applied at proximal LAD and LCX. Subsequently, patient's condition improved and post-procedure ECG showed improvement in aVR and precordial leads, and ST elevation was significantly diminished from V5 and aVR, and R wave came back in V2-V4.Previous study found around 50% of STEMI patients had multi-vessels diseases. In this case, ECG suggested LAD region infarction with ST elevation in aVR, commonly associated with left main stenosis (LMS) involvement.Thrombus aspiration in LAD and LCX yielded hemodynamic improvement. V-stenting technique, introduced in 1996, allows delivery and implantation of 2 stents together, and therefore shorten the stent deployment time.

Autoimmune Disease with Cardiac Valves Involvement: Libman-Sacks Endocarditis.

This case study aim to evaluate the response of steroid treatment for autoimmune endocarditis. Valvular heart disease is relatively rising in both congenital and acquired cases, but the autoimmune endocarditis remains rare. In this case, a 34 year old woman with clinical manifestation resembling systemic lupus erythematosus (SLE) is diagnosed with Libman-sacks Endocarditis. After six months of steroid treatment, her clinical manifestations and heart structure improved.

ST Elevation in Lead aVR and Its Association with Clinical Outcomes.

The purpose of this case repots are to evaluate the role of ST elevation in aVR lead and to make analysis between both cases. There are some atypical electrocardiogram (ECG) presentations which need prompt management in patient with ischemic clinical manifestation such as ST elevation in aVR lead. In this case study, we report a 68-year old woman with chief symptoms of shortness of breath and chest discomfort. She was diagnosed with cardiogenic shock, with Killip class IV, and TIMI score of 8. The second case is a 57-year-old man with typical chest pain at rest which could not be relieved with nitrate treatment. He was diagnosed with ST elevation in inferior and aVR lead, and occlusion in left circumflex artery (LCX). Both patients underwent primary percutaneous coronary intervention (PPCI). Subsequently, both cases presented remarkable clinical improvements and improved ST elevation myocardial infarction (STEMI) in aVR lead.

Effect of PCSK9 E670G and R46L Polymorphisms on Major Adverse Cardio-Cerebrovascular Events in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

Major adverse cardio-cerebrovascular events (MACCE) in ST-segment elevation myocardial infarction (STEMI) are still high, although there have been advances in pharmacology and interventional procedures. Proprotein convertase subtilisin/Kexin type 9 ( PCSK9 ) is a serine protease regulating lipid metabolism associated with inflammation in acute coronary syndrome. The MACCE is possibly related to polymorphisms in PCSK9 . A prospective cohort observational study was designed to confirm the association between polymorphism of E670G and R46L in the PCSK9 gene with MACCE in STEMI. The Cox proportional hazards model and Spearman correlation were utilized in the study. The Genotyping of PCSK9 and ELISA was assayed. Sixty-five of 423 STEMI patients experienced MACCE in 6 months. The E670G polymorphism in PCSK9 was associated with MACCE (hazard ratio = 45.40; 95% confidence interval: 5.30-390.30; p = 0.00). There was a significant difference of PCSK9 plasma levels in patients with previous statin consumption (310 [220-1,220] pg/mL) versus those free of any statins (280 [190-1,520] pg/mL) ( p = 0.001). E670G polymorphism of PCSK9 was associated with MACCE in STEMI within a 6-month follow-up. The plasma PCSK9 level was higher in statin users.