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Acute Coronary Syndromes

Where Is the Culprit Lesion in the New Electrocardiogram Pattern?

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To identify the key insights or developments described in this article

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JAMA Internal Medicine

Published Online: March 7, 2022

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Chuan-Hai Zhang, MD¹;

Zhaolong Xu, MD¹

Author Affiliations

¹Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning, China

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A patient in their 60s presented to the emergency department with paroxysmal chest pain. The chest pain had occurred 5 times during the day, and each episode lasted 15 to 30 minutes. On arrival, the patient’s blood pressure and pulse rate were 106/52 mm Hg and 64 beats per minutes, respectively. Chest auscultation revealed normal breath and heart sounds with no murmurs. The patient’s hemogram, serum electrolyte levels, kidney and liver function test results, and B-type natriuretic peptide and D-dimer levels were all within normal limits. Their cardiac troponin I level was 25 ng/mL (normal, <0.023 ng/mL; to convert to μg/L, multiply by 1). The patient’s initial electrocardiogram (ECG) is shown in the Figure, A. The patient received a diagnosis of acute non–ST-segment elevation myocardial infarction (NSTEMI). On the second day of hospitalization, the chest pain recurred. The repeated ECG taken at the onset of chest pain is shown in the Figure, B.

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Aslanger et al² defined a new ECG pattern comprising 3 criteria: (1) STE in leads III and aVR but not in any other inferior lead, (2) STD in any of leads V₄ to V₆ but not in V₂, and (3) an ST in lead V₁ higher than ST in lead V₂. In this patient, the STD in lead V₂ was inconsistent with these previously described diagnostic criteria. This may be associated with subtotal occlusion of the LMCA. This ECG pattern is common among patients with NSTEMI (6.3%) and is considered a reliable sign of acute inferior MI, indicating occlusion of the RCA or left circumflex artery. The data indicated that 13.3% of inferior MIs might present with this ECG pattern.¹ According to the international guidelines, Aslanger pattern is classified as NSTEMI. However, patients with this ECG pattern have an acute atherothrombotic event that frequently results in an inferior MI with at least 1 accompanying stable, but critical, stenosis in one of the non–infarct-related arteries. Patients demonstrating the Aslanger pattern tend to have larger infarct size, multiple vessel disease, and higher baseline risk and demonstrate an increased short-term and long-term mortality compared with those with other NSTEMIs.

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Article Information

Corresponding Author: Zhaolong Xu, MD, Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Renmin Street, Jinzhou, Liaoning, China 121000 (xuzhaodragon@163.com).

Published Online: March 7, 2022. doi:10.1001/jamainternmed.2022.0011

Conflict of Interest Disclosures: None reported.

References

Aslanger E , Yıldırımtürk Ö , Şimşek B , et al. A new electrocardiographic pattern indicating inferior myocardial infarction. J Electrocardiol. 2020;61:41-46.PubMed Google Scholar Crossref

Aslanger EK , Smith SW . Response to: “A new electrocardiographic pattern indicating inferior myocardial infarction”. J Electrocardiol. 2020;S0022-0736(20)30592-6.PubMed Google Scholar

Yan AT , Yan RT , Kennelly BM , et al; GRACE Investigators. Relationship of ST elevation in lead aVR with angiographic findings and outcome in non-ST elevation acute coronary syndromes. Am Heart J. 2007;154(1):71-78.PubMed Google Scholar Crossref

Ibanez B , James S , Agewall S , et al; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-177.PubMed Google Scholar Crossref

Bozbeyoğlu E , Aslanger E , Yıldırımtürk Ö , et al. The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis. Ann Noninvasive Electrocardiol. 2019;24(3):e12628.PubMed Google Scholar

Thygesen K , Alpert JS , Jaffe AS , et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-2264.PubMed Google Scholar Crossref

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.