Reaching a rapid and accurate clinical diagnosis of acute ST-segment elevation myocardial infarction (STEMI) is critical for a timely reperfusion therapy (1). Distinguishing STEMI from “pseudoinfarction patterns” is frequently challenging for physicians especially those with subtle ECG abnormalities (2, 3). We report the case of an acute anterior STEMI, in a previously well 27-year-old man who presented to the Emergency Department with severe left sided chest pain 1 hour prior to arrival and finally reperfused successfully. Initial 12-lead ECG revealed hyperacute T-wave and subtle concave ST segment elevation morphology as early sign of coronary occlusion. The ECG 1 hour post-thrombolysis revealed improvement of ST-elevation and smaller T waves. The bedside echocardiography showed apical septal and lateral wall hypokinesia. The echocardiography findings and rapid rise of the troponin establishes the diagnosis of STEMI, not “pseudoinfarction patterns”, despite the patient ultimately made an informed refusal of coronary angiography. The classic and obvious ECG changes are ingrained in the emergency physician’s mind, however sometimes other lesser known patterns may initially overlooked. Therefore, expertise in detecting subtle abnormalities is crucial. In patient who has a high likelihood for ischemia, always interpret ST segment abnormalities within larger context of overall ECG morphology and clinical presentation.




Myocardial infarction, Benign Early Repolarization, ST-Segment Elevation, Hyperacute T wave

1. Turnipseed SD, Bair AE, Kirk JD, Diercks DB et al. Electrocardiogram differentiation of benign early repolarization versus acute myocardial infarction by emergency physicians and cardiologists. Acad Emerg Med. 2006 Sep; 13(9):961-6.

2. Kosuge M, Kimura K, Ishikawa T, Endo T et al. Electrocardiographic criteria for predicting total occlusion of the proximal left anterior descending coronary artery in anterior wall acute myocardial infarction. Clin Cardio.2001; 24: 33-38.

3. Smith SW. Upwardly concave ST segment morphology is common in acute left anterior descending coronary occlusion. J Emerg Med. 2006; 31:69-77.
EMAS Meeting 2018 Abtracts