Aslanger Pattern: Another OMI?

13.3% of inferior MIs may present with Aslanger Pattern, and due to being incorrectly labelled as an NSTEMI, be deprived of emergent revascularisation therapy

Aslanger 2020

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 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.

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 of ECG changes in inferior myocardial infarction 2020
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.
  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

Why is there not contiguous ST elevation?
Aslangers-pattern
Diagram adapted from an original by Dr Stephen W. Smith
  • 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
  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

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
  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

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
  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

Associated Persons
  • Emre Aslanger; Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey
  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

Further Examples
Example 1

57 yo female, without previous heart disease except hypertension, presents with chest pain.

  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

References

Historical references

Eponymous term review

  • Physical examination is normal
  • Aetiology is unknown but patients usually have a normal life span
  • Also referred to as “Effort Syndrome” as symptoms resemble those of fatigue following effort in healthy individuals

ECG LIBRARY 700

ECG LIBRARY

Electrocardiogram

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

One comment

  1. I’d be interested to know from someone who is better than me at this how right sided precordial leads would be expected to perform in terms of picking up STE in this scenario.

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