The patient is 79-year-old women has severe aortic stenosis and 2-vessel coronary artery disease s/p coronary artery bypass graft who lives independently and is very active who presented to the emergency department for acute dyspnea.

Seven years earlier she was diagnosed with coronary artery disease. Cardiac catheterization at the time showed a left dominant system with moderate stenosis of the proximal LCx and severe stenosis of proximal PDA, and severe stenosis of the proximal LAD. She had a saphenous vein skip graft to the LCx and PDA, and a internal thoracic artery (LIMA) graft to the mid-LAD. She has declined surgery for her aortic stenosis and has a valve area of 1.1 cm2. Her coronary artery anatomy is shown in the figure below.

Native coronary arteries and a vein skip graft to proximal LCx then PDA and LIMA to mid-LAD.

Native coronary arteries and a vein skip graft to proximal LCx then PDA and LIMA to mid-LAD.

On the day of presentation, she had been doing several loads of laundry, going up-and-down the stairs to her basement about six times. On her last trip she had developed severe shortness of breath. She did not experiencing any chest pain. She was so dyspneic however, that she called her daughter to have her bring her to hospital to “be looked at”. Her daughter was able to arrive with 5 minutes, but the patient was so short of breath she couldn’t walk. EMS was notified who brought the patient to the emergency department.

ECG with 2mm of ST-segment elevation in V1, V2, V3, and aVR with diffuse ST depression.

Prehospital ECG with 2mm of ST-segment elevation in V1, V2, V3, and aVR with diffuse ST depression.

During transport, a 12-lead ECG was obtained. There is 2mm of ST-segment elevation in V1, V2, and aVR, with diffuse ST-depression through the remainder of the leads. On arrival in the emergency de