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Transient ST elevation myocardial infarction (TSTEMI) is not classified in the universal definition of MI. Its existence is not well known hence we illustrated a case to share our experience, whereby we were mystified by the sudden disappearance of myocardial infarction.
A 40 year old gentleman, known case of hypertension, active smoker, presented with a sharp right sided chest pain. Physical examination: unremarkable. Initial ECG showed ST elevation in inferior leads, reciprocal changes in lead AVL, first degree heart block with no right sided heart involvement. Ten minutes later, there was no ST elevation seen in lead II on the cardiac monitor. A repeated ECG showed complete resolution of ST elevation. Troponin I: 11.38(raised). He received aspirin, clopidogrel and S/C clexane without thrombolysis. He remained clinically stable throughout admission. He was discharged well and an angiogram appointment was given.
Transient ST segment elevation is not a nosologic entity but rather a clinical sign that can be attributed by various conditions such as coronary thrombosis, vasospasm or tako-tsubo syndrome. In this case, this gentleman was diagnosed as TSTEMI based on the significant risk factors, history, ECG changes and raised troponin. Spontaneous reperfusion was achieved rapidly due to endogenous fibrinolysis and the presence of recruitable collateral vessels. Regarding the management, should this gentleman receive thrombolysis? The definitive treatment for TSTEMI remains unclear. However, according to a previous study by Meisel et all, data suggest immediate medical therapy with an early angiogram is an appropriate approach. Thrombolysis is not indicated as there is complete resolution of ST elevation.
Albeit there is no evidence of ongoing ischemia, patients with TSTEMI are at high risk of reocclusion. Hospital admission with continuous ECG monitoring is required. Intense medical therapy must be initiated if there is unavailability of a PCI centre.
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