Introduction Embolic myocardial infarction is an uncommon but increasingly recognized complication of infective endocarditis (IE). Its incidence ranges between 1% and 10%, but it has a high mortality rate. A high index of suspicion is required to diagnose it. Only case reports and small studies on this condition have been published; thus, it is unknown what the ideal treatment is. We review the challenges to diagnosing this disease and the most effective treatments for it. Case presentation We report a case series of three patients with acute coronary syndrome (ACS) in IE. The first patient presented with non-ST-elevation ACS. He underwent a stent placement for late-diagnosed embolic myocardial infarction, after which he was treated conservatively without valve replacement, with good results. The second patient with ST-elevation presented with ACS, for which conventional balloon angioplasty and successful double valve replacement were performed. ST-elevation ACS was also observed in the last patient, who experienced periannular complications, which necessitated surgery. Discussion Acute coronary syndrome is a rare complication of IE but is associated with an increased risk of heart failure and high mortality rate. Its management is complicated and cannot be standardized. Because each situation is unique, a multidisciplinary discussion is required to choose the best treatment.

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