Tuesday, August 10, 2021

Why do we liberally record ECGs? And what do you think the angiogram showed?

A 40 something complained of 1 week of constipation and eructation after a "bad batch of enchiladas."  He stated all of this was causing abdominal pain, which he indicated was in the epigastrium.

On exam, he had Right Upper Quadrant tenderness.

A point of care right upper quadrant ultrasound showed + gallstones but no wall thickening or pericholecystic fluid.  No etiology of the pain was established, but a gastric acid related etiology was suspected.

The providers decided after a while that it would be advisable to record an ECG, just in case.  

Here it is:

This ECG was texted to me.  What do you think?  What was my answer?

I said that "This is Aslanger's pattern.  You'd better get an angiogram or at least a stat echo.  It looks like Occlusion MI (OMI)." See below for description of Aslanger's pattern.

There is single lead STE in III, with recipocal STD in aVL (inferior OMI).  There is STD in V3-V6 diagnostic of subendocardial ischemia.

The first troponin returned at 3000 ng/L.


Severe 3 vessel Coronary artery disease involving the LAD

100% mid LCX occlusion.

Formal Echo:

Regional wall motion abnormality--very mild apical septal and apical anterior hypokinesis.

Regional wall motion abnormality--basal to mid inferior and mid inferolateral hypokinesis


This ECG is Aslanger's pattern, and the angiogram is exactly what you expect with this ECG pattern, including the inferior OMI attributed to circumflex (more often than RCA).

This pattern was recently published in J Electrocardiology: Aslanger and others (including Smith).  A new electrocardiographic pattern indicating inferior myocardial infarction.  https://pubmed.ncbi.nlm.nih.gov/32526537/

This newly recognized ECG pattern is defined as:

(1) any STE in III (with reciprocal STD in aVL), but not in other inferior leads, 

(2) STD in any of leads V4 to V6, (but not in V2) with a positive or terminally positive T-wave, 

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

The subendocardial ischemia, with an ST depression vector towards lead II, prevents ST elevation in II and aVF, leaving only lead III to manifest single lead ST Elevation.

Learning Points:

1. Upper abdominal pain may be due to acute MI.  If there is no definite diagnosis (and sometimes even if there is), and ECG and possibly also troponin should be ordered for upper abdominal pain.

2. Aslanger pattern, even if the STE is less than 1 mm (with reciprocal STD in aVL), is diagnostic of OMI in the right clinical situation.   This presentation has a low pretest probability, so obtaining an echo is wise, UNLESS the troponin comes back diagnostic, as in this case.

EKGs filed under "atypical symptoms"

Full echo results:

Decreased left ventricular systolic performance, moderate.

The estimated left ventricular ejection fraction is 35%.

Regional wall motion abnormality-distal septum and apex akinetic.

Regional wall motion abnormality-inferolateral, base.

Regional wall motion abnormality-basal inferior/inferior septum.

Normal right ventricular size with probable RV hypertrophy.

No evidence for left ventricular thrombus.


  1. Great case Steve.. when I first looked at the ECG I saw Infero-Posterior OMI. Was this a Dominant Left-Circumflex Occlusion? Even retrospectively I just really don't see much STE in aVR. I see STE in II, III, aVF, worrisome ST-Takeoff, and relatively large T waves. Furthermore I think there is more STD in V4 than V5. Lead placement could easily account for lack of STD in V2, and for the less than classic (for Posterior MI) depression vector in the precordial leads. Overall I see a very subtle Infero-Posterior OMI and not "Aslanger's Pattern". Interested as always to hear your thoughts on my take. Thanks for sharing the case!

  2. love this post. i guessed RCA, incorrectly.


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