Spotting a novel pattern for myocardial infarction

Abstract Background Aslanger in 2020, identified occlusive inferior myocardial infarction that may not conform to the conventional ST Elevation Myocardial Infarction criteria. Purpose Over the years, several fallacies have emerged regarding the criteria for ST-Elevation Myocardial Infarction. Notable examples include Dewinter’s T waves, Left Bundle Branch Myocardial Infarction, and Wellen’s sign.Recent studies have indicated that approximately twenty-five percent of acute coronary occlusions are missed in instances of non-ST-elevation myocardial infarction (Non-STEMI).The newest innovative tool in this domain- the"Aslanger pattern" transcends conventional STEMI criteria to identify occlusive inferior myocardial infarction. Methods We studied a cohort of fifty patients who presented with anginal chest pain of varying durations and displayed the distinctive Aslanger pattern on ECG. These cases underwent an emergent trans-thoracic echocardiography,coronary angiography(CAG) and mandated revascularisation. Results ECG of all fifty cases revealed the Aslanger pattern:(i)ST Elevation in lead III but not in other inferior leads,(ii)ST depression in any of leads V4 to V6 but not in V2,(iii)ST elevation in lead V1. Echocardiography reflected a spectrum of Left ventricular ejection fraction. On immediate CAG, the Left main coronary artery was involved in eighteen cases, out of which fifteen patients had associated triple vessel disease, two patients had associated double vessel involvement, and one case had associated single vessel involvement. The left anterior descending coronary artery(LAD)was involved in twenty-eight patients, with the majority having the involvement of the proximal LAD.There was a complete occlusion of the LAD in one patient. The Left circumflex coronary artery(LCX)was affected in twenty-one patients, with most cases portraying proximal involvement. There were instances of complete occlusion of the LCX in three patients. Notably, all three cases were characterised by a left dominant coronary circulation.Thirty-one patients had affection of the right coronary artery (RCA), the majority showing lesions of the proximal RCA.There was a complete occlusion of the RCA in twelve cases. Post CAG, thirty-six patients proceeded with angioplasty.Fourteen cases required Coronary artery bypass grafting due to a high SYNTAX score.Furthermore,we have identified an algorithm to diagnose the vessel involvement based on the ECG features. Conclusion The Aslanger pattern originally pertained to an occlusive inferior myocardial infarction secondary to involvement of the RCA or LCX. In our study, the majority of cases had multivessel disease, with the left main coronary artery involvement in 36 percent of cases. This study underscores the importance of recognizing this pattern, predicting the vessel involvement and to formulate an effective management strategy. Awareness of this pattern is vital for embracing the"Time is Myocardium"hypothesis.Culprit artery localisation