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

## TL;DR

This paper presents cases where heart artery blockages were not detected by standard EKGs, highlighting the need for better diagnostic tools.

## Contribution

The novelty lies in demonstrating that normal EKGs can miss severe coronary occlusions, emphasizing the need for improved diagnostic approaches.

## Key findings

- Three patients with severe coronary occlusions had normal initial EKGs.
- EKGs may underestimate ischemia in lateral and posterior heart regions.
- Adjunctive tools like ultrasound and biomarkers are crucial for accurate diagnosis.

## Abstract

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.