A 57-year-old man was admitted with sudden onset of severe central chest pain at rest. The pain was heavy in nature and radiated to both arms. He was sweaty and nauseous. His wife called for an ambulance.
He has a past medical history of type 2 diabetes, hypertension and transient ischaemic attack. The 12-lead electrocardiogram (ECG) in Figure 1 was recorded.
What does the ECG show?
Interpretation of the ECG rhythm
Interpretation of the 12-lead ECG
There is ST segment elevation isolated in lead III and ST depression in V4–V6. This ECG displays the characteristics of Aslanger's ECG.
Standard guidelines for primary percutaneous coronary intervention (PPCI) or thrombolysis have historically required contiguous ST-segment elevation to fulfil ST segment elevation myocardial infarction (STEMI) criteria, i.e. changes are present in two or more adjacent leads.
In April 2020, Aslanger et al (2020) reported a new specific ECG pattern indicating inferior myocardial infarction (MI) that does not display contiguous lead changes. Over 13% of inferior MIs may present with Aslanger pattern, and could therefore be incorrectly labelled as a non-STEMI (NSTEMI) and denied PPCI.
The Aslanger ECG pattern displays:
The Aslanger pattern was observed in 6.3% of NSTEMI patients and found to be a predictor of larger infarct size and higher mortality. This ECG pattern is associated with coronary artery occlusion in patients with multi-vessel coronary disease. Accompanying multi-vessel coronary artery disease predisposes these patients to poor outcomes if the time to reperfusion (PPCI/thrombolysis) is delayed. In this particular case, the right coronary artery was occluded but there was no disease in the other coronary arteries.
The Aslanger ECG presentation joins De Winters, hyperacute T-waves and posterior MI as another indicator of acute occlusion MI (OMI).