Conventional teaching describes a fixed sequence: hyperacute T waves within minutes, ST-segment elevation at approximately 30 min, and pathologic Q waves over hours. No primary study reports that interval; experimental occlusion places ST elevation within 25 to 40 s of ligation. In STAFF III (104 patients, 142 recordings), balloon inflation during elective angioplasty produces complete occlusion with the onset recorded to the second. Three criteria were applied to 10-s windows on a 5-s grid: guideline ST-elevation cutoffs at the J point relative to the PQ junction, the Meyers hyperacute T-wave score, and the Birnbaum terminal QRS distortion definition referred to each patient's own baseline. In leads subtending the occluded artery, ST-segment displacement and the hyperacute T-wave score both exceeded resting variability within 15 s and rose faster during occlusion than at rest (P < .001). Criteria were satisfied within 1 to 2 min: ST elevation in 71 of 104 patients (68%) at 50 s, terminal QRS distortion in 24 (23%) at 80 s, and hyperacute T waves in 16 (15%) at 70 s. Q waves could not be resolved. After deflation, Wellens type A predominated in anterior leads (6.2% vs 1.3% of other leads; P = .001), whereas type B did not. Ischemic electrocardiographic change begins within seconds of abrupt complete occlusion, with the T wave and the ST segment affected together. The traditional interval reflects the intermittent, incomplete occlusion of spontaneous infarction and clinical sampling intervals, rather than any latency in the myocardial response.

The management of acute coronary syndromes remains largely grounded in the ST-elevation myocardial infarction (STEMI)/non-STEMI (NSTEMI) classification, a binary framework that assigns a central role to ST-segment elevation in guiding urgent revascularization. However, a substantial proportion of patients classified as NSTEMI may harbor an acute coronary occlusion, with consequent risk of delayed recognition and adverse clinical outcomes. This review focuses on how the suspicion of acute occlusive myocardial infarction (OMI) can be confirmed in the absence of traditional STEMI criteria. Emphasis is placed on the identification of subtle and dynamic ECG findings, including hyperacute T waves, reciprocal changes, posterior involvement, and evolving repolarization abnormalities, which may indicate ongoing coronary occlusion despite the lack of diagnostic ST-segment elevation. The emerging OMI/non-OMI paradigm challenges the traditional STEMI-centered approach by promoting a physiology-based interpretation of the ECG, integrating clinical presentation and serial biomarker assessment. In this context, the adoption of advanced tools, including artificial intelligence-powered ECG analysis, may enhance early recognition of occlusion patterns and support more timely decision-making. Improving the ability to identify OMI without STEMI criteria represents a critical step toward reducing treatment delays and optimizing clinical outcomes in patients with acute coronary syndromes.

Acute coronary syndrome without ST-segment elevation remains a highly relevant problem due to the heterogeneity of the patient population and the poor prognosis in high-risk groups. Identifying risk factors in this patient group will improve the outcomes of open myocardial revascularization. Aim - to identify factors for adverse outcome of coronary artery bypass grafting in patients with high-risk non-ST-segment elevation acute coronary syndrome.

Amphetamine overdose can cause severe cardiovascular toxicity, including rarely reversible cardiomyopathy. A 26-year-old man presented approximately 33 hours after intentionally ingesting 25 20-mg extended-release mixed amphetamine salt tablets with lorazepam. He developed chest pain, tachycardia, hypotension, hypoxemia, lactic acidosis, rhabdomyolysis, and markedly elevated cardiac biomarkers. Electrocardiography showed diffuse ST-segment depressions, and chest imaging demonstrated bilateral pulmonary edema and acute lung injury without pulmonary embolism. Echocardiography revealed severe global biventricular systolic dysfunction with a left ventricular ejection fraction below 20%. Progressive hypoxemic respiratory failure required intubation and mechanical ventilation. He improved with supportive intensive care, intravenous diuresis, and heart failure therapy. Although coronary angiography was recommended, he declined and left against medical advice. At two-month follow-up, echocardiography showed complete recovery of biventricular function, with an ejection fraction of 55-60%. This case highlights profound but reversible biventricular cardiomyopathy following massive extended-release amphetamine overdose.

Stiff person syndrome (SPS) is a rare autoimmune neurologic disorder that may be accompanied by severe spasms and autonomic instability. We present a man in his 30s with SPS who developed whole-body spasms, severe hypoxemic respiratory failure, and subsequent pulseless ventricular tachycardia/ventricular fibrillation during an attempted extubation at an outside hospital. Initial evaluation demonstrated hyperthermia, shock, ST-segment depression, markedly elevated troponin, and transient severe left ventricular systolic dysfunction; coronary angiography and computed tomography pulmonary angiography excluded obstructive coronary artery disease and pulmonary embolism. After transfer, electrocardiography showed sinus bradycardia with marked QT/QTc (corrected QT interval) prolongation, and while the patient was receiving amiodarone, transesophageal echocardiography showed recovery of left ventricular ejection fraction to 51%, and cardiac magnetic resonance imaging showed patchy mid-wall late gadolinium enhancement with increased T1 and T2 signal compatible with clinically suspected myocarditis. Because endomyocardial biopsy was not performed, the cause of the myocardial injury remained uncertain. Severe hypoxemia, possible sepsis-related myocardial dysfunction, acquired QT prolongation and medication effects, autonomic instability, and cardiac magnetic resonance-supported myocarditis were considered potentially interacting contributors. After recurrent non-sustained ventricular tachycardia and a prior ventricular tachycardia/ventricular fibrillation arrest without a single clearly reversible cause, an implantable cardioverter-defibrillator was placed for secondary prevention. This case illustrates the diagnostic uncertainty surrounding cardiac arrest in SPS and emphasizes the need to evaluate reversible arrhythmic triggers.

ST-elevation myocardial infarction (STEMI) in very young adults is rare and is commonly attributed to non-atherosclerotic mechanisms. Atherosclerotic coronary artery disease in this age group is exceptional and warrants thorough evaluation of contributing risk factors. The increasing prevalence of electronic cigarette use among young individuals raises concern regarding its potential role in premature coronary atherosclerosis.

Anomalous left coronary artery from the pulmonary artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare congenital coronary artery anomaly with an incidence of approximately 1 in 300,000 live births, accounting for 0.25%-0.5% of all congenital heart diseases. Without surgical correction, approximately 90% of affected infants die within the first year of life due to myocardial ischemia and heart failure. However, a small subset of patients with well-developed collateral circulation may survive into adulthood without marked symptoms. We report an incidentally diagnosed case of ALCAPA in a 76-year-old man who was admitted for benign prostatic hyperplasia and urinary retention and underwent cardiovascular evaluation before non-cardiac surgery. Electrocardiography showed sinus bradycardia and complete right bundle branch block, and ambulatory celectrocardiography documented frequent supraventricular premature beats and short supraventricular tachycardia runs without significant ST-T abnormalities. Echocardiography showed a dilated right coronary artery, a suspected coronary fistula, mild chamber enlargement, preserved left ventricular systolic function, and no typical resting segmental wall-motion abnormality. Coronary CT angiography (CTA), performed after cardiology consultation, demonstrated the left main coronary artery arising from the pulmonary trunk, a markedly dilated and tortuous right coronary artery, extensive collateral circulation among the right coronary artery, left coronary system, and bronchial arteries, and a high coronary artery calcium score of 941.74 Agatston units. Cardiac enzymes were not elevated, but formal stress testing and cardiac magnetic resonance imaging were not performed during the index admission. The management decision was therefore framed as individualized conservative follow-up rather than evidence that conservative treatment is generally safe in adult ALCAPA. This case illustrates the diagnostic value of CTA for defining coronary anatomy in late adult ALCAPA, the need for functional ischemia and scar assessment when feasible, and the therapeutic tension between guideline-based surgical recommendations and individualized decision-making in elderly patients with preserved resting ventricular function.