Aslanger Pattern: Another OMI?

By Cristiano Antonino On Dec 12, 2022

In April 2020, Aslanger et al identified a specific ECG pattern concerning for acute inferior occlusion MI (OMI) in patients with concomitant multi-vessel disease, that does not display contiguous ST-segment elevation or fulfil STEMI criteria

The Aslanger Pattern

The publishers reviewed ECG and angiography findings from 1000 NSTEMI, 1000 control (no myocardial infarction), as well as inferior STEMI patients presenting during the same time period.

The Aslanger Pattern was observed in 6.3% of NSTEMI patients and found to be a predictor of larger infarct size and higher mortality.

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ECG Criteria

1) Inferior STE isolated to lead III
2) Concomitant ST depression in any of V4-V6, with a positive/terminally positive T-wave
3) ST segment in V1 > V2

Aslanger pattern 2020

(1) STE in III but not in any other inferior lead,

(2) ST depression in any of leads V4 to 6 (but not in V2) with a positive (at least terminally positive) T-wave,

(3) ST in lead V1 higher than ST in V2.

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Why is there not contiguous ST elevation?

In cases of limited inferior wall injury, the ST vector of inferior MI localises the area of infarction and is typically directed inferiorly and rightwards (yellow arrow)
The ST vector of subendocardial ischaemia does not localise to the ischaemia and regardless of involved coronary region directs to lead aVR (blue arrow)
The resultant average ST vector directs rightwards, causing ST elevation only in lead III and aVR

Aslanger pattern, clinical significance

Concurrent multi-vessel disease predisposes these patients to poor outcomes if there is delayed time to emergent reperfusion, and prompt recognition of this potential OMI should improve outcomes

Identification of the culprit lesion at the time of angiography may be difficult if there is multiple critical stenoses, and this pattern would guide lesions supplying the inferior wall to be opened first

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Limitations

The pattern was found to be present in 0.5% of patients without acute MI, which may be a result of chronic change from a previous ischaemic insult
Acute inferior MI in the presence of previous infarctions may also change the overall orientation of the lesion vector causing a similiar pattern
This is an isolated, retrospective study and warrants a further analysis as a predictor of occlusion MI that would be responsive to emergent reperfusion therapy

Associated Persons

Emre Aslanger; Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey

References

Historical references

Aslanger E, Yıldırımtürk Ö, Şimşek B, Sungur A, Türer Cabbar A, Bozbeyoğlu E, Karabay CY, Smith SW, Değertekin M. A new electrocardiographic pattern indicating inferior myocardial infarction. J Electrocardiol. 2020 Jul-Aug;61:41-46.

Aslanger EK, Smith SW. Response to: “A new electrocardiographic pattern indicating inferior myocardial infarction”. J Electrocardiol. 2020 Nov 18

Eponymous term review

Fiol M, Carrillo A, Cygankiewicz I, Velasco J, Riera M, Bayés-Genis A, Gómez A, Peral V, Bethencourt A, Goldwasser D, Molina F, Bayés de Luna A. A new electrocardiographic algorithm to locate the occlusion in left anterior descending coronary artery. Clin Cardiol. 2009 Nov;32(11):E1-6

Bozbeyoğlu E, Aslanger E, Yıldırımtürk Ö, Şimşek B, Hünük B, Karabay CY, Kozan Ö, Değertekin M. The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis. Ann Noninvasive Electrocardiol. 2019 May;24(3):e12628

Turgay Yildirim Ö, Çanakçı ME. The new ECG pattern for inferior myocardial infarction. J Electrocardiol. 2020 Nov-Dec;63:64

Smith SW. Subtle ECG Findings of Left Anterior Descending Artery (LAD) Occlusion — LAD Occlusion MI (OMI). Vimeo 2020

Smith SW. A 58 year old collapses in the hot sun Dr Smith’s ECG Blog 2020

Smith SW. ECG with Aslanger’s Pattern. CT Pulmonary Angiogram Reveals LAD Ischemia (Septal Transmural). But this is not Contradictory. Dr Smith’s ECG Blog 2021

Buttner R. OMI: Replacing the STEMI misnomer. LITFL 2021

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