Pseudonormalization ST-segment in ST-elevation Myocardial Infarction Patient

Author : F.Fathini, R. A. Seriulina,A. Ginanjar, T. T. Dewi, I.A. Rakhmawulan, D. Rostiati
Upload Date : 19-04-2018

Background: Pseudonormalization (PN) of ECG in Acute Coronary Syndrome has been reported to be associated with severe, transmural myocardial ischemia. Myocardial ischemia patients usually present with obvious ECG abnormalities, such as ST-segment depression or elevation, which enable immediate and appropriate treatment. However, occasionally patients with pre-existing abnormalities on ECG reverted completely to isoelectric ST-segment. Usually these ECG changes are mistakenly interpreted, and adequate treatment may be missed.

Methods: A 50 years-old male came with chief complain of typical angina onset 10 hours accompanied by diaphoresis with no other complication. The risk factors for coronary artery disease were smoking and dyslipidemia. The ECG showed STEMI in inferior wall with reciprocal in anteroseptolateral wall. While the patient being observed, the ECG rhythm turned into sinus rhythm with isoelectric ST-segment and positive T waves. Angiography done the next day show total coronary occlusion in RCA (right coronary artery).

Results: The mechanisms of PN has not been completely interpreted. It may be the sum of the ST-segment elevation and the amplitude of T-waves of acute ischemia, plus, the preexisting ST-segment depression and the degree of T-wave inversion, results in isoelectric ST segment and upright T-wave. Angiographically, PN patients have severely narrowed or totally occluded coronary arteries, with unstable plaques, large thrombus, and underdeveloped coronary collaterals. PN can be spontaneous or non-spontaneous, non spontaneous PN usually found during coronary angioplasty, exercise stress test, and dobutamine echocardiography. Moreover, spontaneous PN is usually rare but definite finding for severe myocardial ischemia.

Conclusions: Pseudonormalization is uncommon findings and it is typically associated with severely narrowed or totally occluded coronary arteries. Serial recordings of ECG monitoring in patients with anginal symptoms is valuable to detect this circumstances. Knowledge of the phenomenon may help decision making for appropriate management.

KEYWORDS : pseudonormalization, acute coronary syndrome, electrocardiography

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