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

Abstract

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.

Keywords: Acute Myocardial Infarction; Aslanger’s pattern; Critical coronary stenoses; Revascularization; ST-segment elevation.

Fig. 1

The patient’s timeline from onset of symptoms to treatment. ECG = Electrocardiogram, STE = ST-segment elevation, NSTEMI = Non ST-segment elevation myocardial infarction, PCI = Percutaneous coronary intervention

Fig. 2

Central Illustration. The patient first electrogram (ECG) in admission in emergency. Bold arrows indicated ST elevation in lead III. Double arrows indicated greater ST segment elevation in lead V1 than V2. Triangles indicated ST segment depression in lead V4-V6 with lead V6 positive T wave and positive terminal vector V4-V5 T wave

Fig. 3

ECGs at different times after admission. A was taken when leaving emergency room. B was taken when admission in coronary ward. C and D were taken under his chest pain attack

Fig. 4

Coronary angiography and intervention. A-C indicated severe stenoses of left main artery(LM) and left anterior descending artery(LAD). D-F indicated stents insertion in the lesion of LM and LAD. G-H were angiography after intervention

Fig. 5

The follow-up ECG one month after operation