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NSTEMI with total left circumflex occlusion: how the N-wave might help (case report)

Mochamad Yusuf Alsagaff1, Louisa Fadjri Kusuma Wardhani1, Iswanto Pratanu1

  • 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Airlangga University-Dr Soetomo General Hospital Surabaya, Surabaya, Indonesia.

Oxford Medical Case Reports
|February 24, 2022
PubMed

Insights

A subtle ECG finding, the 'N-wave' pattern, can indicate acute total coronary artery occlusion in non-ST-segment myocardial infarction (NSTEMI) patients, prompting crucial early intervention for heart attack management.

Area of Science:

  • Cardiology
  • Diagnostic Imaging

Background:

  • Myocardial infarction (MI) diagnosis relies on troponin levels, but ECGs can be normal in some cases.
  • Type 1 and Type 2 myocardial infarcts are indicated by rising or falling troponin levels.

Observation:

  • A patient with chest discomfort presented with normal ECG and echocardiography.
  • Serial high-sensitivity troponin tests revealed a significant rise, indicating a high-risk non-ST-segment myocardial infarction (NSTEMI).
  • An 'N-wave' pattern was observed on the ECG, a subtle finding not yet a guideline criterion.

Findings:

  • An early invasive procedure revealed acute total occlusion (TO) in the obtuse marginal 1 branch.
  • The 'N-wave' ECG pattern was identified retrospectively in 10% of NSTEMI cases with Left Circumflex artery (LCx) occlusion.

Implications:

  • The 'N-wave' pattern may serve as an early indicator for prompt angiography in NSTEMI patients with non-diagnostic examinations.
  • Recognizing this subtle ECG finding can improve the diagnosis and management of acute coronary occlusions, particularly in the LCx.
  • This highlights the importance of considering subtle ECG changes in conjunction with troponin levels for timely MI diagnosis.

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