An unusual case of left anterior descending coronary artery occlusion—anterior ST depression and inferior ST elevation

We report a case of a 51-year-old man with chest pain, sweating, and breathlessness for a few hours. He was a smoker, reporting neither history of heart disease nor other cardiovascular risk factors: he was not receiving any drug therapy. At emergency room, an electrocardiogram (ECG) showed an unusual type of ST-segment depression in V2-V6 leads, thus suggesting an involvement of left anterior descending (LAD) coronary artery (Fig. 1). Systolic arterial blood pressure at admission was 90/60 mm Hg, and physical examination was unremarkable. Chest radiography showed no sign of pulmonary congestion, with a normal cardiac transverse diameter. Suddenly, ventricular fibrillation appeared, necessitating a 250 Joule DC shock to restore sinus rhythm. After a while, a second ECG showed ST-segment elevation in V2-V6—DI leads associated with an intraventricular delay of conduction. The patient was immediately transferred into the coronary care unit where a third ECG unexpectedly showed ST-segment elevation in inferior leads (Fig. 2), mimicking an inferior acute myocardial infarction (AMI). The patient immediately underwent systemic fibrinolysis with tenecteplase, able to reverse any sign of ST-segment elevation (Fig. 3). Echocardiography showed anterior, septal, apical, and lateral akinesis, with mild mitral regurgitation and left ventricular ejection fraction b35%. A coronary angiography performed within 24 hours unexpectedly showed a severe narrowing at proximal LAD (Fig. 4): no other signs of severe coronary atherosclerosis were present. After coronary angioplasty with sirolimus-eluting stent, the patient was discharged with aspirin, clopidogrel, statins and β-blockers. Negative V2-V6–DI-aVLTwaves were