DOI: https://doi.org/10.36347/sjmcr.2026.v14i03.055

Pages: 549-552

Background: Delayed myocardial infarction presentations can show subtle or non‑diagnostic ECG changes despite acute coronary occlusion, particularly in patients with diabetes. Case: A 65‑year‑old woman with type 2 diabetes presented 36 hours after persistent constrictive chest pain radiating to the left arm and jaw. She was hemodynamically stable. ECG showed sinus rhythm with first‑degree AV block and minimal ST elevation in lead III with reciprocal depression in I and aVL, not meeting formal STEMI criteria. High‑sensitivity troponin rose markedly; bedside echocardiography demonstrated inferior wall hypokinesis with preserved LVEF (53%). Management and outcome: Given high clinical suspicion, she received aspirin and prasugrel and was taken for urgent angiography, which revealed a proximal thrombotic RCA occlusion and a critical proximal LAD stenosis. PCI of the RCA with two drug‑eluting stents restored TIMI 3 flow without complications. She recovered in the CICU and was discharged after 48 hours on guideline‑directed therapy. Conclusion: This case highlights the need to integrate clinical presentation, biomarkers, bedside imaging, and early invasive assessment in delayed or atypical MI—especially in diabetics—to achieve timely revascularization and favorable outcomes.