Tombstoning ST-segment elevation myocardial infarction(STEMI) has been associated with a poor prognosis ever since Wimalaratna’ s first description of this clinical entity, and the reasons for this are not fully understood. We studied 87 consecutive patients who had anterior STEMI(January 2004 to September 2004) to compare the form of STEMI, coronary anatomy, and initial N-terminus pro-brain natriuretic peptide(NT-pro-BNP) level. Patients who had tombstoning STEMI had higher levels of NT-pro-BNP despite significant differences in cardiac enzyme levels or extent of coronary disease. This finding suggests that, in addition to changing the shape of repolarization, decreased microcirculation plays a role in the development of increased wall tension. Increased wall tension in turn is the probable cause of higher NT-pro-BNP levels and increased mortality.