Multiple Culprit Arteries in Patients With ST Segment Elevation Myocardial Infarction Referred for Primary Percutaneous Coronary Intervention

In most cases of acute ST-segment elevation myocardial infarction, only 1 epicardial artery contains an occluding thrombus, commonly referred to as the “culprit” artery. Rarely, however, patients present with >1 acutely thrombosed coronary artery (i.e., “multiple culprits”). The investigators present their experience with 18 patients presenting with ST-segment elevation myocardial infarctions and angiographically documented multiple culprit arteries, provide a detailed review of an additional 29 patients previously reported, and summarize baseline characteristics, pertinent electrocardiographic and angiographic findings, laboratory values, and clinical outcomes for all 47 patients. In this case series, most patients were men (85%) with histories of tobacco use (49%). Although nearly 1/3 of the patients had isolated inferior ST-segment elevation on initial 12-lead electrocardiography, 50% of them had simultaneous thrombotic occlusions of the right coronary and the left anterior descending coronary arteries documented on coronary angiography. These patients were hemodynamically unstable on presentation, with >1/3 in cardiogenic shock. In most cases, no other potential predisposing factors were identified. In conclusion, patients with multiple culprit arteries in the setting of ST-segment elevation myocardial infarctions represent a unique population with high rates of cardiogenic shock and no clear cause.