Case

A 70-year-old male was diagnosed with non-ST-elevation myocardial infarction (NSTEMI) without signs of haemodynamic compromise and intermediate GRACE risk scores (Fig. 1a). Initial cardiac biomarkers were elevated with a creatine kinase of 1236 U/l and positive high sensitive troponin of 787 ng/l. He was scheduled for coronary angiography within 24 h. One and a half hours after admission the pain had not resolved despite medical therapy, and it was decided to perform immediate angiography. To our surprise, occlusion of a large left anterior descending artery (LAD) was found with collaterals from the right coronary artery. Subsequent successful percutaneous coronary intervention of the LAD was performed (Fig. 1b and c). The procedure was successful with TIMI-3 flow and myocardial blush grade 3. After the procedure the patient remained free of symptoms and during further observation no complications occurred.

Figure 1
figure 1

a Electrocardiogram on admission. 25 mm/s, 10 mm/mV. b Left coronary artery in RAO caudal angulation. Before intervention. c Left anterior descending artery in RAO cranial view. After PCI with implantation of a 3.5 mm drug-eluting stent

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Conclusion

ST-segment elevation only may not always reflect ongoing ischaemia and we should no longer focus on the presence or absence of ST-segment elevation as a reliable criteria to proceed or to postpone urgent angiography and/or reperfusion therapy [1, 2]. Future studies should focus on the NSTEMI ACS algorithm and its identification of high-risk patients who may benefit from urgent coronary angiography and subsequent revascularisation [3, 4, 5]. In our opinion, the acute myocardial infarction classification based on ST elevation alone should be reconsidered.