This ECG of the Month case and discussion evaluates the appropriate management of transient ST-segment elevation (STE) — defined as STE meeting STEMI criteria that resolves spontaneously or with medical therapy — focusing on timing of coronary angiography and risk stratification in the ED setting.
10–20% of initial STEMI presentations show STE resolution before or on ED arrival. Critical coronary stenosis is present in ~60% (≥95% stenosis) to ~90% (≥70% stenosis) of these patients. The TRANSIENT trial (n=142) and ELISA-3 subgroup (n=129) found no significant difference in 30-day MACE between immediate and delayed/early angiography strategies, though 5.6% of delayed-strategy patients in TRANSIENT required urgent intervention for reinfarction while waiting.
Evidence base is limited to two small randomized trials (combined N=271), both underpowered to detect clinically meaningful differences. The ELISA-3 data are from a post-hoc subgroup analysis, limiting causal inference. Findings apply only to patients with complete resolution of both STE and symptoms.
For patients with complete resolution of both STE and symptoms, admit as high-risk NSTEACS, start dual antiplatelet and anticoagulant therapy, and obtain immediate cardiology consultation to determine angiography timing (early invasive within 24–72 hours is reasonable). Escalate to emergent angiography for persistent or recurrent STE, hemodynamic instability, electrical instability, or ongoing symptoms despite medical therapy.
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