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A 56 year old male smoker with a one year history of hypertension presented with a two hour history of severe, tight, central chest pain. Examination revealed that he was sweating profusely and had cold peripheries. His blood pressure was 90/60 mm Hg and auscultation of the chest revealed evidence of pulmonary oedema. The electrocardiogram showed sinus rhythm with broadening of the QRS complexes and widespread ST/T wave changes suggestive of cardiac ischaemia, but not fulfilling conventional criteria for thrombolysis. He was treated with aspirin, diamorphine, and intravenous heparin, and transferred to the cardiac catheter laboratory where angiography demonstrated proximal thrombotic occlusion of the left main coronary artery (A). The right coronary was ectatic, with no flow-limiting stenosis and there was some retrograde collateral filling of the left coronary.
After discussion with the cardiac surgeons, insertion of an intra-aortic balloon pump, and administration of abciximab, a guidewire was passed through the occlusion with some immediate improvement in antegrade flow (B). Balloon angioplasty resulted in improved flow but as there was some residual stenosis (C). A 16 mm Multilink intracoronary stent (Guidant ACS, Basingstoke, UK) was inserted with an excellent angiographic result (D). He was started on ticlopidine and the balloon pump was removed 36 hours after the procedure. Predischarge angiography confirmed persistence of the excellent angiographic result and a left ventricular ejection fraction of approximately 40%. At follow up eight weeks later he was asymptomatic on medical treatment (angiotensin converting enzyme inhibitor, diuretic, and aspirin).
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