Transient T-wave pseudonormalization and U-wave inversion during recurrent left anterior descending coronary ischemia: a case report

Abstract Background Strict reliance on traditional ST-segment elevation myocardial infarction criteria can miss acute coronary occlusion. Serial comparison is particularly important when previously inverted T waves become upright during recurrent symptoms. Case presentation We report a 70-year-old man with dynamic T-wave alterations and subthreshold ST-segment changes. Initial angiography showed a 95% mid-left anterior descending artery stenosis with Thrombolysis in Myocardial Infarction (TIMI) 2 flow. Immediate percutaneous coronary intervention was recommended but declined after symptom relief despite risk counseling. During recurrent chest pain, transient T-wave pseudonormalization and subtle negative post-T-wave deflections were initially underrecognized. Temporary symptom relief and failure to compare earlier ECGs contributed to continued observation. Medically refractory symptoms and serial ECG changes prompted repeat angiography, which confirmed progression to subtotal occlusion with TIMI 1 flow. Two overlapping stents restored TIMI 3 flow. At 1.5 months, the patient remained asymptomatic, with upright precordial T waves and normal cardiac function on echocardiography. Conclusions This serial ECG–angiographic correlation illustrates the importance of interpreting dynamic repolarization abnormalities alongside symptoms and known coronary anatomy. An apparently improved isolated ECG should not delay urgent reassessment of recurrent ischemia.