The pathogenesis of acute myocardial infarction (AMI) is rupture of coronary artery plaque resulting in acute thrombotic occlusion of a coronary artery that is the “culprit” lesion, but on rare occasions this culprit lesion can be found in more than 1 artery. This is rare and has poor prognosis. Here, we report a case of acute myocardial infarction (AMI) with simultaneous total occlusion of the left anterior descending artery (LAD) and right coronary artery (RCA).

A 56-year-old male presented to the emergency department with sustained chest pain and diaphoresis since past 3 hours. He was chronic smoker since past 15 years. Patient was on antihypertensive drugs since last 2 years .He had no history of diabetes mellitus or family history of coronary artery disease. On presentation his blood pressure was 140/90 mm Hg and physical examination revealed no abnormality. His lung fields were clear. The initial 12 lead electrocardiogram showed a sinus rhythm with ST segment elevation in leads II,III, aVF, and V2-V5 (Figure 1). The echocardiographic examination showed hypokinetic wall motion abnormality of mid distal anteroseptal , apical and basal inferior wall of left ventricle , with left ventricular ejection fraction(LVEF) of 40%. Patient was in killip class 1 and TIMI score was 2/14 (hypertension, anterior lead ST elevation). Patient was started on antiplatelets, statin, heparin and was taken for primary percutaneous coronary intervention (PCI). Coronary angiography showed anomalous origin of LCX from right coronary sinus (Figure 2) and total occlusion with suspected thrombus formation in mid RCA and mid LAD (Figures 3 and 4). Patient underwent successful PCI, with drug eluting stent implantation in both LAD and RCA. Further hospital stay was uneventful and patient was discharged on day four.

AMI commonly occurs through occlusion of a coronary artery by atheromatous plaque rupture followed by thrombus formation [1]. In the present case, this phenomena occurred simultaneously in two coronary vessels. Incidence of double-vessel coronary thrombosis may account for 1.7% to 4.8% of all primary PCIs [2]. Although rarely reported in most series of patients admitted for AMI, autopsy studies reveal that thrombotic occlusion of more than one major epicardial coronary artery is not uncommon, occurring in up to 50% of patients with infarction [3]. By contrast, Pollak et al. found 18 cases (2.5%) of multiple culprit arteries in a series of 711 patients undergoing primary PCI. This discrepancy is probably due to selection bias in that patients with multiple.culprit arteries are more likely to suffer sudden cardiac death, not surviving long enough to undergo angiography [2]. It is often fatal, resulting in sudden cardiac death, and thus accurate diagnosis of multivessel coronary occlusion is rarely achieved in clinical settings. Further, even if these patients are admitted, hospital mortality rate is still high. Most of these patients have evidence of hemodynamic instability, with approximately 1/3 of patients had cardiogenic shock, and nearly 1/4 of patients had life-threatening arrhythmias or required intra-aortic balloon pumps [2]