A proposal for better visualization of Aslanger pattern

Atypical Aslanger pattern in inferolateral myocardial infarction - A new variant to look out for?

We report a case of a 53-year-old male with inferolateral myocardial infarction, presenting an atypical Aslanger pattern on electrocardiogram (ECG). The ECG showed ST elevation in leads III, aVR, aVF, and posterior leads, with ST depression in II and V2-V6 with terminal positive T waves. Coronary angiography revealed total occlusion of the left circumflex artery (LCx) with significant stenosis of the left anterior descending (LAD) and right coronary artery (RCA). The LCx was successfully revascularized. This case highlights the importance of recognizing atypical Aslanger patterns, which may indicate multivessel coronary artery disease.

A patient with acute myocardial infarction with electrocardiogram Aslanger's pattern

BACKGROUND

Aslanger's pattern in electrocardiogram (ECG) indicates that patients may have acute inferior myocardial infarction(AMI) with concomitant critical stenoses on other coronary arteries, which needs to be evaluated the timing of revascularization as risk equivalents of ST elevation myocardial infarction(STEMI).

CASE PRESENTATION

The patient was a 62-year-old male with chief complaint of intermittent exertional subxiphoid pain for 20 days from 30th June. One day after the last episode (19th July), the 18-lead electrocardiogram showed ST segment elevation of 0.05-0.1mV in lead III, ST segment depression in leads I, avL, and V2-V6, T wave inversion with positive terminal vector in lead V4-V5, and positive T wave in lead V6, which indicated Aslanger's pattern. With increased Troponin I (0.162ng/mL, 0-0.02), The patient was diagnosed as acute non-ST-segment elevation myocardial infarction (NSTEMI) and admitted to coronary ward on 20th July. The coronary angiography showed 95% stenosis in the distal left main coronary artery (LM) to the ostium of the left anterior descending artery (LAD), 90% stenosis in the proximal segment of the LAD, and 80% stenosis in the middle segment of the LAD, and TIMI blood flow was graded score 2. Three drug-eluting stents were implanted at the lesions. The patient's ECG returned close to normal one month after revascularization.

CONCLUSION

We presented an acute coronary syndrome case whose ECG showed with Aslanger's pattern (i.e., isolated ST-segment elevation in lead III, associated ST-segment depression in lead V4-V6 with positive T wave/terminal vector, and greater ST-segment elevation in lead V1 than in lead V2), and was confirmed severe stenosis of the LM and the proximal segment of the LAD via coronary angiography. In clinical practice, especially in the emergency, patients with ECG presenting Aslanger's pattern should be urgently evaluated with prompt treatment, and the timing of emergency coronary angiography and revascularization should be evaluated to avoid adverse outcomes caused by delayed treatment.