ReviewFrontiers in cardiovascular medicine2026
Clinical characteristics and diagnostic challenges of non-ST-segment elevation acute coronary syndrome patients with normal electrocardiograms: a review.
Review in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Abstract
Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) represents a major subtype of acute coronary syndrome (ACS). A clinically relevant but often overlooked subgroup of patients presents with typical ischemic symptoms despite a normal initial 12-lead electrocardiogram (ECG), creating real diagnostic difficulty. This narrative review synthesizes current evidence across several domains: epidemiology, pathophysiology, clinical presentation, diagnostic evaluation, and management of NSTE-ACS patients with normal ECGs. A structured literature search of PubMed, Web of Science, and the China National Knowledge Infrastructure (CNKI) databases, with emphasis on prospective cohort studies, registries, systematic reviews, meta-analyses, and current European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations. Depending on the definition of "normal ECG" and study population, approximately 1%-8% of confirmed NSTE-ACS patients present with a normal initial ECG. These patients frequently exhibit single-vessel disease, non-obstructive coronary artery disease, or alternative mechanisms such as coronary vasospasm and microvascular dysfunction. High-sensitivity cardiac troponin (hs-cTn) assays using rapid 0/1-h or 0/2-h algorithms constitute the diagnostic cornerstone, while coronary computed tomography angiography (CCTA) provides valuable anatomical assessment, particularly in low-to-intermediate-risk patients. This review presents an integrated diagnostic algorithm, critically evaluates the complementary roles of multimodality imaging techniques, and discusses future directions including artificial intelligence-assisted ECG interpretation and wearable monitoring technologies.
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