A patient with non-ST-segment elevation acute coronary syndrome: Is it possible to predict the culprit coronary artery?

•An elaboration on the likelihood of different culprit arteries is made in a patient with non-ST-segment elevation acute coronary syndrome by interpreting serial ECG changes in conjunction with evolving symptoms.•Typical ECG findings of ischemia in the left coronary territories were diminishing during worsening symptoms.•Dynamic T-wave changes were present in inferior leads.

In acute coronary syndromes without ST-segment elevation (NSTE-ACS), identification of the culprit artery is, most often, not possible. In this case report, we elaborate on the likelihood of different culprit arteries in a patient with NSTE-ACS. While her symptoms were progressing, typical ECG findings of ischemia in the left coronary territories were diminishing. Instead, dynamic T-wave changes in the inferior leads were present and were most likely postischemic and “reischemic.” Although the culprit artery could not be identified with certainty by means of these subtle changes, they correlated well with the findings on angiography and the ECG recorded afterward. This case report demonstrates the importance of analyzing ECG and its temporal changes in conjunction with evolving symptoms.