A patient in their 70s with a history of nonischemic cardiomyopathy and biventricular pacemaker presented to the emergency department with 2 days of intermittent chest pain, which had become constant for 4 hours and associated with diaphoresis and shortness of breath. Vital signs were normal, and a 12-lead electrocardiogram (ECG) was obtained (Figure). Two hours later the patient had an episode of polymorphic ventricular tachycardia.
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Questions: Are there any clinical or ECG indications for cardiac catheterization laboratory activation, and what angiographic findings does the ECG predict?
The ECG shows atrial-sensed biventricular pacing with a premature ventricular contraction. Although the pacing is biventricular (which usually has a near-normal QRS duration), the structure is that of right ventricular pacing, with a wide and negative QRS complex throughout the precordium. With such a QRS complex, all leads should have secondary ST-T segment changes discordant to (in the opposite direction of) the QRS complex. But here there is subtle concordant ST-segment elevation in lead III only, with reciprocal concordant ST-segment depression in leads I and aVL. While this does not meet the modified Sgarbossa criteria of 1 mm of concordant ST-segment elevation, it is accompanied by an ST-segment in lead V1 higher than lead V2 and mild concordant ST-segment depression in leads V2 through V6. This represents the Aslanger pattern in a paced rhythm, which identifies inferior occlusion myocardial infarction (OMI) with concomitant critical stenoses. In addition, this was followed by polymorphic ventricular tachycardia, which in the context of ischemic symptoms is a sign of electrical instability from OMI. The patient, therefore, had both clinical and ECG indications for cardiac catheterization laboratory activation, despite not meeting ST-elevation MI (STEMI) criteria.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Jesse T. T. McLaren, MD, Department of Family and Community Medicine, University Health Network, 200 Elizabeth St, R. Fraser Elliott Building, Ground Floor, Room 480, Toronto, ON M5G 2C4, Canada (firstname.lastname@example.org).
Published Online: April 3, 2023. doi:10.1001/jamainternmed.2023.0096
Conflict of Interest Disclosures: Dr Smith reported personal fees from Cardiologs, HEARTBEAM, Rapid AI, and Baxter/Veritas; and holding stocks from Powerful Medical and PulseAI outside the submitted work. No other disclosures were reported.
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