Anterior wall MI presenting as inferior wall MI in a young patient: a case report of wraparound LAD

Introduction and importance: Acute myocardial infarction (AMI) is diagnosed based on clinical presentation and ECG changes that localize the infarct site. Inferior wall myocardial infarction (MI) typically results from right coronary artery (RCA) occlusion, whereas anterior wall MI is due to left anterior descending artery (LAD) obstruction. Rarely, a wraparound LAD supplying both anterior and inferior walls causes anterior MI to present with inferior ST elevations, which may lead to diagnostic confusion. Recognizing such anatomical variants is crucial, especially in young patients without conventional risk factors. Case presentation: A 38-year-old male without diabetes, hypertension, or dyslipidemia presented with acute retrosternal chest pain radiating to both shoulders. ECG suggested Inferior Wall MI. Coronary angiography revealed a normal RCA, stenosis in the mid-LAD, and thrombotic occlusion of the distal LAD. Primary PCI with balloon angioplasty and stenting was performed. The LAD was identified as a wraparound variant supplying the inferior wall. An apolipoprotein assessment showed a low ApoA1 level and a high ApoB:ApoA1 ratio (1.53), indicating elevated cardiovascular risk despite a normal lipid profile and Lp(a). Clinical discussion: This case highlights the importance of considering coronary anatomical variations when ECG and angiography findings are discordant. A wraparound LAD can explain inferior ST elevations in anterior MI. Standard lipid profiles may miss elevated atherogenic risks, whereas apolipoprotein ratios provide improved risk assessment. Conclusion: Wraparound LAD infarction may mimic inferior wall MI on ECG, risking delayed diagnosis. Coronary angiography and advanced lipid testing, including apolipoprotein profiling, are essential for accurate diagnosis and management in atypical AMI presentations.