A 50-year-old male presented to our facility in emergency department with complaints of breathlessness since last three hours. He had a known history of hypertension and denied any history of diabetes mellitus. On arrival, his heart rate was 137 beats/min, blood pressure was 170/110 mmHg and blood oxygen saturation on room air was 80%. He was initially suspected to be covid-19 positive. However, he was afebrile on presentation and also denied any history of coughing. Furthermore, he reported history of chest pain and epigastric pain since morning. He was tested negative on covid-19 rapid antigen testing kit. His echocardiography showed 30% left ventricular ejection fraction and hypokinesia in the left anterior descending region.

Considering his blood oxygen saturation levels, he was put on Bipap support and his electrocardiogram (ECG) showed anterior wall myocardial infarction (Figure 1). His blood oxygen saturation levels improved with bipap support. Patient was given 180 mg ticagrelor and 300 mg aspirin. He was put on nitroglycerine drip and was advised for coronary angiography. His angiography revealed normal right coronary artery and left circumflex artery. Total occlusion with heavy thrombus burden was observed in proximal left anterior descending artery (LAD) (Figure 2A). After thrombus suction (Figure 2B), the lesion was predilated with a short length balloon. A 3.5 x 28 mm sirolimus-eluting stent (Ultimaster [Terumo, Tokyo, Japan]) was negotiated in the lesion and deployed (Figure 2C). The lesion was postdilated with a 4 x 12 mm balloon. Final check shoot showed TIMI III flow with no residual stenosis (Figure 2D). His chest discomfort was relieved post percutaneous coronary intervention (PCI). Post PCI, his ECG showed >50% resolution in ST segment (Figure 3). He tolerated the procedure well in the first 24 hours.

On the next day, he was taken off the Bipap support, his morning electrolytes and ABG were in normal range. Later that day around 5 pm, he complained of giddiness with some perspiration. His ECG was taken immediately which showed, normal sinus rhythm with new onset Left Bundle Branch Bock (LBBB) with QRS interval of 146 ms and PR interval was 124 ms (Figure 4). We did his check angiography which showed flowing stent. Post angiography after 30 min, He again had giddiness and felt transient loss of consciousness.  His ECG showed LBBB bradycardia with heart rate of 57/min and had transient, 2:1 AV block pattern on the monitor. which immediately reverted to normal sinus rhythm with LBBB (Figure 5).  We suspected that, the use of ticagrelor might have caused the conduction abnormality, Hence, he was switched from ticagrelor to prasugrel.  He was closely monitored in the coronary care unit, and, we also planned to do temporary pacing if needed. Patient had episode of complete heart block for a duration of about 10 seconds at night which was reverted with intravenous use of Theophylline (5mg/kg) (Figure 6). On the next day, his ECG showed NSR and resolution of LBBB (Figure 7). He was continued on prasugrel and was discharged after 48 hours of uneventful observation.