PMC9834149_01
(A) ECG at Emergency Department. Negative and symmetrical T waves in leads DI, DII, aVL, aFV and from V2 to V6 and ST-segment elevation of 2 mm in V3 and of 1 mm in V4 and V4 (red arrows). (B) ECG normalization after PCI. (C) ECG during shock. Sinus tachycardia with ST-segment elevation of 1 mm in leads DI and DII and of 3 mm in leads V2 and V3. ST-segment depression of 1 mm in lead aVR (red arrows)
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A 74-year-old woman in good clinical condition, presented to the emergency department with acute anterior STEMI (Killip class I-II), normal blood pressure and LVEF of 35% with apical akinesia and mid-apical septal hypokinesia on transthoracic echocardiogram (TTE; Figure 1, Table 1, Video S1a). Thrombolysis in myocardial infarction (TIMI)-III flow and regression of STE on electrocardiogram (ECG) were achieved (Figures 1B and 2C; Video S2c), then the patient was transferred to the intensive coronary care unit (ICCU; Table 1). Sinus tachycardia associated with anterolateral STE and reciprocal depression on lead aVR were shown on ECG (Figure 1C).
(A) Coronary angiography: occlusion of the first tract of the LAD (red arrow) (caudal angulation). (B) Coronary angiography: occlusion of the first tract of the LAD (red arrow) (cranial angulation). (C) Coronary angiography after PCI: TIMI-III flows of the LAD (red arrow) (caudal angulation). (D) Coronary angiography during shock: no AST nor coronary vasospasm (caudal angulation)
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Through PCI, a 12-mm- length zotarolimus-eluting stent was placed over the proximal tract of the LAD, where a critical occlusion was found (Figure 2A,B; Video S2a,b). Thrombolysis in myocardial infarction (TIMI)-III flow and regression of STE on electrocardiogram (ECG) were achieved (Figures 1B and 2C; Video S2c), then the patient was transferred to the intensive coronary care unit (ICCU; Table 1). Subsequently, intra-aortic balloon pump (IABP) was placed and cardiogenic shock due to both acute stent thrombosis (AST) and to a hypersensitivity coronary artery reaction resulting in Kounis syndrome (KS), was ruled out by performing again CA, that showed normal flow over all coronary arteries (Figure 2D; Video S2d).