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Multivessel spontaneous coronary artery dissection is a very rare cause of myocardial ischemia. Its optimal treatment is not yet well defined and is usually tailored to clinical features. We report a case of a postpartum woman with multivessel spontaneous coronary artery dissection and acute myocardial infarction, in whom the drug-eluting stenting of the only alleged 'culprit' vessel did not prevent the propagation of dissection from another vessel. Although the recommendations drawn from a single case report are not conclusive, we believe that when there is a multivessel spontaneous coronary artery dissection in a setting of acute myocardial infarction, all dissected coronary segments should be treated using stents.

The optimal management of acute myocardial infarction in elderly people (>or= 75 years) is controversial because elderly patients have been excluded or are under-represented in most acute myocardial infarction trials. Randomized studies show that, also in the elderly, thrombolytic therapy is effective in reducing mortality after acute myocardial infarction but the benefit in terms of mortality, recurrent infarction and stroke is smaller compared to primary percutaneous coronary intervention. Among the available mechanical therapeutic strategies, stenting is found to be superior to balloon angioplasty, whereas the role of drug-eluting stents in this setting still remains to be evaluated. The standard use of intravenous unfractionated heparin is still recommended because of the increased risk of intracranial haemorrhage by a combination of low molecular weight heparin or IIb/IIIa inhibitors and thrombolytic agents. Dedicated randomized clinical trials are needed to establish the best reperfusion therapy for this expanding population, especially in patients admitted to hospitals without percutaneous coronary intervention facilities and in patients developing cardiogenic shock.