Silence of the Electrocardiogram: A Case Series With Occluded Coronaries and Normal Electrocardiograms

Every year over a million patients present with acute coronary events. A substantial number of patients present with non-ST-segment elevated myocardial ischemia (NSTEMI), and a subset of those have normal-looking electrocardiograms (EKG). We report three cases of patients that had near-to-complete occlusions of coronary arteries with an initial nondiagnostic EKG. Silent EKG findings in the setting of coronary occlusion represent a significant challenge that may delay time to reperfusion. Our cases indicate that EKG alone may underestimate the severity of ischemia, particularly in the lateral and posterior territories. This emphasizes the importance of adjunctive tools such as ultrasound and cardiac biomarker assessment. Further research must be done to determine the risk of myocardial ischemia (MI) in normal EKG, including research in minor EKG changes, and further algorithms that could identify risk in patients in nondiagnostic EKG.