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

A rise and/or fall in troponin level is an indication of type 1 or 2 myocardial infarct. A 62-year-old male physician presented to emergency room with chest discomfort followed by thought to be normal electrocardiogram (ECG) and normal echocardiography results. His serial hs-troponin test showed remarkable escalation three hours from the initial (107 ng/l into 4.978 ng/l), suggesting a high-risk non-ST-segment myocardial infarction (NSTEMI). An early invasive procedure was performed, showing acute total occlusion (TO) in the obtuse marginal 1 branch. We retrospectively reviewed our examination to diagnose better the presence of TO in NSTEMI patients presented with non-diagnostic examination. Our evaluation showed a minor change in the form of an ‘N-wave’ pattern on the ECG, which was not yet an established guideline criterion for prompt angiography. Although ECG pattern is often normal in LCx occlusion, recent study shows the presence of ‘N-wave’ ECG pattern in 10% of NSTEMI cases following TO at LCx.