In a 58‑year‑old asymptomatic woman with no hypertension, a resting heart rate of 90 beats/min, mild inferior ST‑T wave changes on a 12‑lead ECG, and a normal N‑terminal pro‑B‑type natriuretic peptide level, what is the most appropriate initial management?

Management of Asymptomatic Inferior ST-T Wave Changes in a 58-Year-Old Woman Scheduled for Surgery

This patient does not require urgent cardiac intervention or delay of surgery based on her presentation. The combination of mild inferior ST-T wave changes, normal NT-proBNP, and absence of symptoms indicates low short-term cardiovascular risk.

Initial Risk Assessment

The patient's ECG findings represent nonspecific changes that carry prognostic but not acute diagnostic significance. Mild ST-T wave abnormalities (defined as ST deviation <0.5 mm or T-wave changes <2 mm) are less diagnostically helpful for acute coronary syndrome and do not suggest active ischemia requiring immediate intervention 1, 2.

Key Distinguishing Features Present:

• Normal NT-proBNP effectively excludes acute cardiac stress – Values <300 ng/L indicate low risk for cardiovascular events and argue against heart failure or significant myocardial injury 1
• Asymptomatic presentation – Absence of chest pain, dyspnea, or other ischemic symptoms substantially reduces likelihood of acute coronary syndrome 1
• Resting heart rate of 90 bpm – Within normal range and not suggestive of hemodynamic compromise 1
• Non-hypertensive – Eliminates hypertensive emergency as a consideration 3

Appropriate Management Pathway

Immediate Actions (Pre-operative):

• Proceed with scheduled surgery without delay – The patient does not meet criteria for acute coronary syndrome or unstable angina, which would require postponement 1, 2
• No urgent cardiac catheterization indicated – Absence of ST elevation, significant ST depression (≥0.5 mm), or elevated biomarkers means invasive evaluation is not warranted 1, 2
• Serial ECGs are unnecessary – These are indicated only when initial ECG is non-diagnostic but clinical suspicion for ACS remains high with ongoing symptoms 1, 2

Risk Stratification Context:

Inferior lead ST-T changes in asymptomatic patients represent chronic findings rather than acute pathology. While minor ST-T abnormalities are associated with increased long-term cardiovascular mortality (hazard ratio 1.60-2.10 for coronary heart disease death over 22 years), they do not indicate acute risk requiring immediate intervention 4, 5. These changes are more common with advancing age and in certain populations, and may reflect subclinical coronary disease or left ventricular hypertrophy 1, 6.

Post-operative Outpatient Evaluation

Within 2-4 Weeks After Surgery:

• Exercise stress testing – Recommended to evaluate for inducible ischemia in asymptomatic patients with minor ECG abnormalities, particularly given upcoming surgical stress 1, 6
• Echocardiography – Assess for left ventricular hypertrophy, which can produce ST-T changes mimicking ischemia, especially in inferior leads 1, 7
• Cardiovascular risk factor assessment – Evaluate for hypertension, diabetes, hyperlipidemia, and smoking history to guide long-term prevention strategies 1

If Stress Test is Normal:

• No restrictions on surgical clearance – Normal functional testing in asymptomatic patients with minor ECG changes indicates low short-term risk 1, 6
• Initiate guideline-directed preventive therapy based on identified risk factors (statin if indicated, blood pressure control, lifestyle modification) 1
• Annual follow-up with repeat ECG to monitor for progression 1

Critical Pitfalls to Avoid

Do not treat this as acute coronary syndrome. The absence of symptoms, normal biomarkers (NT-proBNP), and minor nature of ECG changes (<0.5 mm ST deviation) clearly distinguish this from NSTEMI or unstable angina 1, 2.

Do not delay surgery for non-invasive or invasive cardiac testing. Immediate cardiac evaluation is indicated only for patients with high-risk features: refractory angina, hemodynamic instability, life-threatening arrhythmias, or ongoing ischemia with symptoms 2. This patient has none of these.

Do not misinterpret normal NT-proBNP. Values <300 ng/L provide strong negative predictive value against acute cardiac events and heart failure, supporting the decision to proceed with surgery 1.

Consider alternative causes of inferior ST-T changes including left ventricular hypertrophy (which can produce pseudo-Wellens pattern), early repolarization, positional changes, or chronic findings unrelated to acute pathology 1, 2, 7.