Antiphospholipid syndrome is a disorder characterized by arterial and venous thromboses, thrombocytopaenia and stroke. Acute myocardial infarction is rarely associated with this syndrome. The treatment of these patients is a clinical challenge. This report is about a patient with antiphospholipid syndrome presenting with an acute myocardial infarction after an exercise test. The infarct-related coronary artery was successfully revascularized by primary angioplasty and stenting without any major bleeding complications. We think that the physical exertion could have favoured acute coronary thrombosis in this particular setting.

The electrocardiogram, when applied in the prehospital setting, has a significant effect on a patient with chest pain. The potential effect includes both diagnostic and therapeutic issues, including the diagnosis of acute myocardial infarction and the indication for thrombolysis or invasive procedures. We report the case of a man who suffered from a syncope, with a prehospital electrocardiogram showing prominent ST-segment elevation. Out-of-hospital thrombolytic therapy was planned by the emergency department. Fortunately, thrombolysis did not start because the patient fared worse. He was taken to the emergency department and, because of mental status impairment, it was decided to perform a cranial computed tomographic scan. The diagnosis shifted to a haemorrhagic stroke. According to the guidelines, prehospital thrombolysis would have been inappropriate in this case because the patient did not have any chest discomfort. The pathophysiological mechanisms of electrocardiographic abnormalities in the setting of intracranial haemorrhage are reviewed, as well as the issue of thrombolysis administered or planned only on the basis of an electrocardiogram.

The right coronary artery originating from the left coronary system is an extremely rare variation of the single coronary artery anomaly in which the prognosis is usually benign provided that the anomalous vessel does not cross between the aorta and the pulmonary artery. The clinical significance of coronary anomalies is usually determined by underlying anatomic features of the wrong coronary origin and/ or coronary atherosclerosis. Although coronary angiography is an important diagnostic method, new non-invasive methods such as coronary computed tomography angiography and cardiac magnetic resonance imaging have important roles to play in characterizing this coronary anomaly. It should be noted that the management strategy of these patients may vary based on clinical presentation, anatomical details and additional findings. We describe a case of a man with occasionally detected right coronary artery originating from the left coronary system, treated with coronary artery by-pass because of critical two vessel disease. The anomalous right coronary artery was surprisingly untouched from atherosclerotic lesions.

A 82-year-old man with hypercholesterolemia, hypertension and glucidic intolerance, presented with angina pectoris upon exertion. The vital signs were normal. Echocardiography showed normal left ventricular (LV) ejection fraction, non-critical aortic valvular stenosis and LV diastolic dysfunction. Rest and stress myocardial echocardiography showed a reversible abnormal septal-wall motion.Therefore, an initial diagnosis of possible coronary artery disease was made. Coronary arteriography showed no atherosclerotic lesions in the 3 major coronary arteries; however, in the anterior descending artery a communication with the right ventricle (RV) cavity through five small, diffuse fistulae was detected (Figure 1 and 2), resulting in complete RV contrast opacification.The patient was stabilised on medical therapy because he refused any further invasive therapy.

Isolated right ventricular (RV) myocardial infarction (MI) is an extremely rare phenomenon and may be difficult to recognize. Also, it is rare to observe ST elevation in anterior leads caused by isolated, transient small acute marginal branch occlusion. We described the case of an acute RV MI with transient ST segment elevation in precordial leads from V1 to V4, due to isolated RV branch occlusion during right coronary artery stenting. Figure 1: The basal Ecg shows normal ST-T segment in the inferior leads and minimal ST segment depression in the precordial leads.