title: The absence of the ST-segment elevation in acute coronary artery thrombosis: what does not fit, the patient or the explanation?
abstract: In a few patients with acute proximal thrombotic occlusion of the left anterior descending coronary artery (LAD), tall ischemic T waves never evolve into ST-segment elevation. This was recently inaccurately reported as a "novel sign" of proximal LAD occlusion. It has been speculated that the absence of ST-segment elevation could be attributed to the large area of transmural ischemia, the anatomic variant of Purkinje fibers, or to lack of activation of sarcolemal adenosine triphosphate-potassium channels. This electrocardiographic picture was recently explained by changes in the subendocardial but not in the epicardial action potential, suggesting subendocardial ischemia as the underlying mechanism. We present a patient with thrombotic lesion of proximal LAD, static precordial ST-segment depression, and tall T waves who underwent primary percutaneous intervention and stent placement. Surprisingly, total thrombotic stent occlusion on the following day was associated with ST-segment elevation in precordial leads, indeed supporting the concept of the regional subendocardial ischemia that was first described more than a decade ago.
authors.affiliation: Department of Cardiology, Clinical Hospital Center Zemun, Belgrade University School of Medicine, Belgrade, Serbia. future.ivan@gmail.com
authors.forename: Ivan
authors.initials: I
authors.lastname: Stankovic
authors.forename: Ivan
authors.initials: I
authors.lastname: Ilic
authors.forename: Milos
authors.initials: M
authors.lastname: Panic
authors.forename: Alja
authors.initials: A
authors.lastname: Vlahovic-Stipac
authors.forename: Biljana
authors.initials: B
authors.lastname: Putnikovic
authors.forename: Aleksandar N
authors.initials: AN
authors.lastname: Neskovic
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D000208:Acute Disease; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000175:diagnosis*; D023921:Coronary Stenosis / Q000175:diagnosis*; D003951:Diagnostic Errors / Q000517:prevention & control*; D004562:Electrocardiography / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged