Original Article

 Primary PCI in a 78-Year-Old Female Patient With STEMI Due to Total Occlusion of Distal RCA: A Case Report

Yong Suk Jeong¹

Abstract

Background/Objectives: ST-elevation myocardial infarction (STEMI) is a time-critical condition requiring prompt diagnosis and intervention. Elderly patients pose additional challenges due to comorbidities and potential delays in treatment

Methods: A 78-year-old woman presented with acute chest pain and diaphoresis. ECG showed inferior ST-segment elevation. Coronary angiography revealed total occlusion of the distal right coronary artery, and primary PCI with thrombus aspiration and drug-eluting stent implantation was performed under intravascular ultrasound guidance.

Results: Successful stent deployment restored TIMI 3 flow without complications, with preserved left ventricular function.

Conclusions: Prompt diagnosis and image-guided primary PCI can be safely and effectively performed in elderly patients with STEMI.

Keywords

STEMI, elderly, PCI, RCA occlusion, intravascular imaging, drug-eluting stent

Introduction

ST-elevation myocardial infarction (STEMI) represents one of the most critical presentations of acute coronary syndrome, requiring rapid recognition and timely reperfusion therapy. Primary percutaneous coronary intervention (PCI) remains the preferred treatment strategy for STEMI, with superior outcomes compared to thrombolytic therapy when performed within appropriate time frames. 

In elderly patients, however, management of STEMI poses significant clinical challenges. Advanced age is associated with delayed presentation, increased comorbidities, greater anatomical complexity, and higher procedural risk. Despite these concerns, several studies have shown that elderly patients can benefit from prompt PCI, achieving comparable success and survival rates when appropriately selected and managed.

We report a case of a 78-year-old female who presented with acute inferior wall STEMI caused by total occlusion of the distal right coronary artery (dRCA). Through rapid triage, effective team-based care, and imaging-guided PCI, complete revas-cularization was achieved with favorable outcome. This case emphasizes the im-portance of prompt intervention and multidisciplinary coordination in high-risk elderly patients.

Case Presentation

A 78-year-old female with a medical history of hypertension and dyslipidemia presented to the outpatient clinic with complaints of sudden-onset chest discomfort, nausea, epigastric discomfort, and cold sweating. While waiting for evaluation, she experienced worsening chest pain and was urgently referred to the emergency department.

On arrival, the patient was alert and oriented. Initial vital signs were stable: blood pressure 144/64 mmHg, heart rate 58 beats per minute, respiratory rate 18 breaths per minute, body temperature 36.5°C, and oxygen saturation of 100% on room air. Physical examination revealed no murmurs or rales, and the abdomen was soft and non-tender with normal bowel sounds.

Electrocardiography (ECG) revealed ST-segment elevation in leads II, III, and aVF, consistent with inferior wall STEMI. Cardiac biomarkers were mildly elevated (Troponin-I 0.020 ng/mL), and AST was 159 U/L. N-terminal pro-BNP was 376 pg/mL. Point-of-care transthoracic echocardiography showed preserved left ventricular ejection fraction (LVEF 56%) with new regional wall motion abnormalities in the right coronary artery (RCA) territory. Mild mitral regurgitation, mild-to-moderate tricuspid regurgitation, and estimated right ventricular systolic pressure (RVSP) of 43 mmHg indicated mild pulmonary hypertension.Given the diagnosis of acute inferior STEMI, the patient was promptly consented and transferred to the catheterization laboratory (CTL; Angio-room) for primary PCI. The total time from symptom onset to angio-suite arrival was under 25 minutes.

Investigations

Twelve-lead electrocardiography demonstrated ST-segment elevation in leads II, III, and aVF, consistent with acute inferior wall ST-elevation myocardial infarction (STEMI). Transthoracic echocardiography revealed a preserved left ventricular ejection fraction (LVEF) of 56%. However, new regional wall motion abnormalities were observed in the right coronary artery (RCA) territory. Additional findings included mild mitral regurgitation, mild-to-moderate tricuspid regurgitation, and an estimated right ventricular systolic pressure (RVSP) of 43 mmHg, suggestive of mild pulmonary hypertension.

Initial laboratory evaluation revealed a mild elevation in cardiac biomarkers, with Troponin-I at 0.020 ng/mL and AST at 159 U/L, suggesting early myocardial injury. N-terminal proBNP was measured at 376 pg/mL, indicating mild ventricular strain in the context of acute ischemia. Other parameters, including hemoglobin, platelet count, and PT-INR, were within normal limits. The patient's lipid profile showed borderline total cholesterol and near-optimal LDL levels. HbA1c was 5.5%, indicating good glycemic control. A summary of the patient’s laboratory results is provided in Table 1.

Intervention / Procedure

The patient was transferred to the cardiac catheterization laboratory within 25 minutes of symptom onset. Vascular access was obtained via the right femoral artery using a 7 Fr sheath. A JR 4.0 guiding catheter was used to engage the right coronary artery (RCA). Angiography revealed a total occlusion of the distal RCA(Figure 1), consistent with the culprit lesion for the inferior STEMI. Additional findings included diffuse 60–70% stenosis in the left circumflex artery (LCX) and a milking effect with up to 50% narrowing in the mid-left anterior descending artery (mLAD).

As show in the Figure 2, A SION Blue guidewire was advanced into the posterior left ventricular (PLV) branch of the RCA. Thrombus aspiration was performed using an Eliminate aspiration catheter, which successfully restored distal flow to TIMI grade 3. A 3.5 × 33 mm Xience sp drug-eluting stent was then deployed at the site of occlusion. Due to suboptimal stent expansion on initial angiography, post-dilatation was performed using a 4.0 × 15 mm Raiden balloon .

Intravascular ultrasound (IVUS) confirmed proper stent apposition and full expansion. No residual dissection or thrombus was noted. The final angiogram demonstrated complete restoration of blood flow in the RCA, with no procedural complications(Figure 3).

Key procedural details are summarized in Table 2. The intervention was performed efficiently with successful restoration of TIMI 3 flow and no procedural complications. Intravascular ultrasound was used to guide post-dilatation and confirm optimal stent deployment.

Table 2. Laboratory and Diagnostic Test Results at Admission

Figure 1. (A) Baseline coronary angiography showing total occlusion at the distal right coronary artery (white arrow), consistent with the culprit lesion in inferior STEMI. No distal flow is visualized beyond the occlusion. (B) Coronary tree schematic illustrating the location of the culprit lesion at the distal right coronary artery (dRCA), where a 3.5 × 33 mm drug-eluting stent (Xience sp) was deployed. The stented segment is shaded in blue, corresponding to the site of total occlusion treated during primary PCI.

Figure 2. Sequential coronary angiographic images demonstrating the stages of stent deployment in the distal right coronary artery (dRCA). (A) SION blue-intervention image. (B) IVUS image. (C) Stent deployment using a 3.5 × 33 mm drug-eluting stent (white arrow). (D) Balloon inflation during post-dilatation (white arrow). (E) Final angiogram confirming restored 1 flow and well-expanded stent (white arrow).

Figure 3. Coronary angiography and Electrocardiogram (ECG) findings before and after intervention. (A) Pre-intervention coronary angiography shows total occlusion of the distal right coronary artery (RCA) within the dotted box. (B) Corresponding 12-lead ECG reveals ST-segment elevation in leads II, III, and aVF, consistent with acute inferior myocardial infarction. (C) Post-intervention angiography after primary percutaneous coronary intervention demonstrates successful reperfusion of the distal RCA with restored TIMI grade 3 flow (dotted box). (D) Follow-up ECG shows resolution of ST-segment elevations in the inferior leads and normalization of QRS morphology, indicating successful myocardial reperfusion

Clinical timeline

Total door-to-balloon time: approximately 65 minutes, well within the recommended 90-minute window for optimal reperfusion therapy.

Outcome and Follow-Up

Following successful stent deployment and restoration of TIMI 3 flow in the distal right coronary artery, the patient was transferred to the coronary care unit (CCU) for post-procedural monitoring. She remained hemodynamically stable with no evidence of recurrent chest pain or arrhythmia. Serial cardiac enzymes showed a peak in troponin-I without further elevation, consistent with completed infarction.

Daily electrocardiograms revealed resolving ST-segment elevations in the inferior leads. Echocardiography performed on day 2 of admission confirmed preserved left ventricular ejection fraction (EF 59%). There were no immediate or delayed procedural complications, including access site bleeding, contrast-induced nephropathy, or arrhythmias. The patient was started on dual antiplatelet therapy (aspirin and clopidogrel), a beta-blocker, a statin, and an angiotensin-converting enzyme inhibitor.

She was discharged on day 4 of hospitalization in good condition, with instructions for outpatient cardiac rehabilitation and follow-up evaluation. At the 6-month outpatient visit, she remained symptom-free with no evidence of recurrent ischemia or heart failure.

Discussions

ST-elevation myocardial infarction (STEMI) in elderly patients presents a clinical challenge due to increased comorbidity burden, atypical symptom presentation, and higher procedural risk. Nevertheless, multiple studies have shown that timely primary percutaneous coronary intervention (PCI) significantly reduces mortality and improves functional outcomes in elderly patients, particularly when performed within guideline-recommended timeframes [1,2].

In this case, a 78-year-old woman with inferior STEMI due to distal right coronary artery (dRCA) occlusion underwent successful primary PCI within 45 minutes of presentation. This is consistent with current guidelines from both the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC), which recommend a door-to-balloon time of ≤90 minutes for PCI-capable hospitals [1,3].

Intravascular ultrasound (IVUS) was utilized to guide post-dilatation and confirm optimal stent apposition. Imaging guidance during PCI has been associated with improved outcomes and lower restenosis rates, especially in complex lesions and elderly patients [4].

Although the routine use of thrombus aspiration is not recommended, selective use may be beneficial in cases of large thrombotic burden, as in this patient [5]. In this case, aspiration restored TIMI 3 flow with no distal embolization or complications.

Importantly, the patient’s cumulative radiation exposure (260.91 mGy air kerma) remained well below safety thresholds, aligning with international recommendations for radiation safety in interventional procedures[6].

This case highlights that chronological age alone should not be a deterrent to reperfusion therapy. With appropriate triage, team-based care, and imaging-guided strategy, elderly STEMI patients can achieve outcomes comparable to younger populations. Post-procedural care including guideline-directed medical therapy (GDMT) and cardiac rehabilitation are crucial in optimizing long-term prognosis [1,3].

Conclusions

This case demonstrates that primary percutaneous coronary intervention (PCI) can be safely and effectively performed in elderly patients presenting with ST-elevation myocardial infarction (STEMI). Early recognition, rapid triage, and the use of imaging-guided techniques played a pivotal role in achieving successful revascularization and favorable clinical outcome.

Despite advanced age, the patient benefited from evidence-based reperfusion therapy without complications, highlighting that age alone should not preclude aggressive management. This case underscores the importance of adhering to current STEMI guidelines and applying individualized, team-based care approaches in older adults with acute coronary syndromes.

Conflict of Interest

The authors have no conflicts of interest to declare and agreed to the published version of the manuscript.

Author Contributions

JYS conceived and designed the study, conducted all experiments and data analyses, interpreted the results, and wrote the entire manuscript. The author reviewed and approved the final version of the manuscript.

References

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