A 60-year-old male patient visited Chonnam National University Hospital with ongoing chest pain for 6 hours. He had no past history of hypertension, diabetes mellitus, and familial history of coronary artery disease. He was a social drinker and non-smoker.
Physical examination revealed no abnormal murmur or irregular beat on heart sound. He showed normal sinus rhythm on electrocardiogram (ECG) (Figure 1). Cardiac enzymes were elevated with troponin-I (2.19 ng/mL) and CK-MB (42.3 U/L). So we diagnosed non-ST elevation myocardial infarction (NSTEMI). After he took sublingual nitroglycerine, he did not feel chest pain anymore. Coronary angiography (CAG) would be performed the next day because he had relieved chest pain and stable vital sign.

His CAG showed significant stenosis in distal left circumflex artery (LCX) and middle left anterior descending artery (LAD) with collateral flow to right coronary artery (RCA) (Figure 2. A). Right CAG showed total occlusion in proximal RCA (Figure 2. B). Plain old balloon angioplasty (POBA) was done using 2.0 mm balloon in proximal to middle RCA. Follow up angiogram showed intact flow of RCA, but the significant stenosis was remained. So we implanted the stent using 3.0 x 28 mm endothelial progenitor cell (EPC) capture stent (Genous® stent) in this lesion. Final CAG showed good distal flow without residual stenosis (Figure 3). Because his blood pressure was dropped under 80 mmHg and he complained of chest pain during stenting, the procedure was ended without performing additional PCI for LCX or LAD lesion. We decided to consider 2nd stage PCI.

The next day echocardiography was done. It showed myocardial infarction compatible with RCA territory. Myocardial Single Photon Emission Computed Tomography (M-SPECT) was done for identifying viability to decide to do PCI for LCX or LAD. M-SPECT showed moderate, medium sized, reversible perfusion defect in mid to basal inferolateral wall (Figure 4). It meant ischemic lesion of LCX territory could be improved by revascularization. And so we performed POBA using a 2.5 mm balloon, followed by stenting using a 2.75 x 15 mm EPC capture stent (Genous® stent). The final CAG showed TIMI III antegrade flow without residual stenosis (Figure 5).

At discharge, the patient did not complain of chest discomfort anymore. He was prescribed aspirin 300 mg, clopidogrel 75 mg, cilostazol 200 mg, and atorvastatin 40 mg daily.
Which strategy is better between culprit-only PCI and multi-vessel PCI in patients with non-ST elevation MI? An American College of Cardiology National Cardiovascular Database Registry reported that performance of multi-vessel PCI appeared to be associated with at least as successful an inhospital outcome as culprit-only PCI in patients with multi-vessel coronary artery disease (CAD). Also multi-vessel revascularization in multi-vessel CAD presenting with NSTEMI showed better clinical outcomes without significant in-stent restenosis and progression of diseased-vessel compared to culprit-only revascularization in Korea Acute Myocardial Infarction Registry (KAMIR) data. But we should select PCI strategy in view of various conditions.