Culprit Lesion Seen 1 Hour Before Occlusion
Limits of Coronary Angiography in Detecting Vulnerable Plaques
A 58-year-old man with recent inferolateral myocardial infarction was admitted to our critical care unit after an episode of typical chest pain. At hospital admission, the physical examination was normal, and an ECG performed after the resolution of symptoms showed signs of the previous myocardial infarction and a mild (0.5 mm) up-slowing ST-segment elevation in leads V3 through V6, with resolution in the following ECGs. Blood samples revealed raised troponin levels. Coronary angiography showed subocclusive stenosis of the mid left circumflex (LCx) artery (Figure, A). Furthermore, the left anterior descending (LAD) artery exhibited a 50% uncomplicated stenosis (Figure, B). The LCx stenosis was treated by stent implantation with optimal angiographic results (Figure, C). An hour after the procedure, the patient suffered from increasing chest pain, refractory to endovenous nitrates and associated with ST-segment elevation in precordial leads. Urgent coronary angiography showed total occlusion of the LAD at the site of the previously noted nonsignificant stenosis (Figure, D). A drug-eluting stent was then deployed with optimal angiographic results (Figure, E). This case provided the opportunity to assess coronary anatomy at angiography immediately before an acute occlusion, highlighting the limitations of the “luminogram” provided by coronary angiography. It also confirms that the mechanism responsible for the transition from stable to unstable coronary syndromes does not operate at the site of a single plaque but affects the whole coronary circulation.