The painless ST-elevation myocardial infarction equivalent: a case report

Abstract

This report presents the case of a 61-year-old patient who experienced sporadically occurring episodes of chest pain lasting approximately 15 minutes. The initial electrocardiogram (ECG) showed unspecific repolarization disturbances but no ST-elevation indicative of ST-elevation myocardial infarction (STEMI). However, upon closer examination, biphasic T waves were detected, suggestive of specific repolarization abnormalities. The conventional Wellens criteria were met, possibly indicating an etiopathogenetic correlation with the patient's complaints. Subsequent coronary angiography revealed a functional occlusion of the middle segment of the left anterior descending artery, which was treated by percutaneous transluminal coronary angioplasty/drug eluting stent. It also revealed a severely stenosed distal circumflex artery, indicating a two-vessel coronary disease. If we had used only conventional STEMI criteria, this patient would have certainly been missed. Therefore, when evaluating patients presenting with chest pain, it is imperative to consider non-occlusion infarction ECG abnormalities, known as STEMI equivalents. This case, moreover, highlights the importance of the non-officially proposed occlusion myocardial infarction (OMI)/non-OMI paradigm instead of the old STEMI/non-STEMI dichotomy.

Figure 1

(A) Initial electrocardiogram (ECG) with a Wellens type-A morphology V2, V3, and possibly V4, preserved R progression and non-significant ST depression laterally (V5, V6, I, aVL), and a T wave flattening or maybe slight inversion, which we judged to be a non-specific repolarization disturbance. (B) Focused display: besides classical morphology of Wellens type A, we see how, in V2 and V3, the terminal T wave inversion is frequently only slightly emphasized. It forms a disproportionately small part of the whole width of the T wave; V4 appears more as a symmetrical “up-down” T wave.

Figure 2

(A) The Wellens syndrome, diagnostic criteria according to Rhinehardt (1). (B) Progressive electrocardiogram (ECG) of our patient with borderline positive ST-elevation myocardial infarction (STEMI) criteria over the anterior wall. (C) The white arrow indicates the location of the coronary artery occlusion affecting the middle segment of the left anterior descending artery (right anterior oblique 44/cranial 26 projection).