A middle-aged man with mild coronary artery disease and dyslipidemia referred to us at 8am for primary percutaneous coronary intervention. He presented earlier with left sided chest pain, crushing in nature, radiating to left arm and jaw with diaphoresis started at 7am which prompting for urgent evaluation. Initial assessment revealed that GCS full of pain score 7/10, blood pressure 197/127 heart rate 100 beat per minute lung clear and no murmur in cardiovascular assessment. 

An electrocardiogram (ECG) revealed ST elevation in the anteroseptal leads and reciprocal changes in the inferior leads. Transthoracic echocardiography (TTE) showed an ejection fraction of 40% with hypokinetic anterior segments, effectively ruling out aortic dissection, mitral regurgitation, ventricular septal rupture, and pericardial effusion. Patient was classified as Killip Class I. Other investigation showed normal full blood count, renal function and liver function test. Troponin was 147. 

Punctured at right radial approach with terumo method 6FR and diagnostic shot over right system with optitorque 6FR revealed normal right coronary artery. Coronary angiogram showed 80% stenosis in the proximal left anterior descending (LAD) artery with short left main artery. Normal left circumflex artery as well. Not much thrombus seen at the proximal LAD. 

Recognizing the urgency of the situation, the patient was rapidlytransferred to our center for primary percutaneous coronary intervention (PCI).Coronary angiography revealed significant 80% stenosis in the proximal left anteriordescending (LAD) artery. We employed an Extra-Backup (EBU) 3.5 6FR guidecatheter for optimal support and access, meticulously wiring the LAD with aRun-Through Floppy (RTF) guidewire. Stability was further enhanced with a SionBlue guidewire for the left circumflex (LCx) artery.Following predilation with a scoring balloon (2.5 x 15 mm) at 12 atm, wedeployed a BioFreedom stent (3.0 x 33 mm) at 16 atm. The procedure includedcareful post-dilation with a non-compliant balloon (3.5 x 15 mm) at 20 atm toensure optimal stent expansion, followed by additional proximal stent dilationwith a 4.0 x 12 mm balloon at 16 atm to improve blood flow dynamics. Thismeticulous approach successfully restored TIMI 3 flow with no immediatecomplications.

Post-procedure, the patient experienced an uneventful recovery and was discharged in stable condition, underscoring the critical importance of timely intervention in acute myocardial infarction. This case illustrates the rapid assessment and intervention required in managing acute coronary syndromes, highlighting the effectiveness of PCI in restoring blood flow and preserving myocardial function. Early recognition and swift action can significantly impact patient outcomes, reaffirming the need for vigilant monitoring and rapid response in acute cardiac care.