Dual Culprit ST-Elevation Myocardial Infarction: A Rare but Complex Clinical Entity

Dual culprit ST-elevation myocardial infarction (STEMI) refers to the simultaneous involvement of two different coronary arteries, both of which contribute to the ischemic event. It is distinct from multiple plaque ruptures in a single vessel and poses additional challenges, especially regarding timely and effective intervention. Dual culprit STEMI presents several unique diagnostic and management challenges that differentiate it from traditional single-vessel STEMI. The simultaneous involvement of two different coronary artery territories can lead to an atypical presentation and complicate clinical decision-making. Diagnosing dual culprit STEMI requires a high degree of clinical suspicion and thorough imaging. Electrocardiogram (ECG) findings may be more diffuse and nonspecific than in single-vessel STEMI, as ischemic changes may be observed in multiple coronary artery territories. Coronary angiography remains the gold standard for diagnosis. However, the challenge lies in identifying both culprit lesions during the acute phase of the STEMI. The management of dual culprit STEMI poses unique therapeutic challenges, particularly in deciding which vessel to treat first, and how to manage the other lesion(s) within the constraints of the acute setting. Dual culprit STEMI carries a higher risk of adverse outcomes compared to single-vessel STEMI. The presence of two culprit lesions is associated with a larger area of myocardial ischemia, which can lead to higher rates of heart failure, arrhythmias, and mortality. Here, we discuss two cases of dual-culprit STEMI and an approach to diagnosis and management.