Abdominal Pain in a middle-aged patient

I was texted this case by Ankur Kalra, an interventional cardiologist at the University of Indiana.  He also did his cardiology fellowship at my institution, Hennepin County Medical Center.

He runs the Parallax podcast, and he inteviewed me on that Podcast this year.

He says the podcast had over 3000 downloads and "It's our season 6 topper"

Here it is:

Ep 121: OMI/NOMI: A Paradigm Shift in Myocardial Infarction Diagnosis With Dr Stephen Smith

By the way, also don't miss this new OMI review article (January 17, 2025) in Annals of Emergency Medicine:

ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review

Case

Dr. Kalra texted me this ECG on a Sunday Morning:

Patient with abdominal pain.  No chest pain.  hs Trop I is 15,000.  I think it is OMI.  Taking her to the cath lab.

My response: "This looks like a subacute (possibly spontaneously reperufused) first diagonal.  Could be LAD.  But it is definitely OMI.  T-wave inverted in aVL and starting to invert in V2."

This ECG has the "South Africa Flag Sign"

This image below illustrates the "South Africa Flag Sign" (Image is from this previous post).  It is a sign of STE or Hyperacute T-wave in V1, I, aVL, with reciprocal ST depression in lead III.

It is a sign of first diagonal occlusion, or sometimes of LAD occlusion proximal to the first diagonal.

Quiz post: do either or both of these patients have high lateral OMI / South African flag sign?

I sent the ECG to the Queen of Hearts PMCardio AI Model for her diagnosis:

His response:

"Wow!  I will let you know"

The interventionalist sent this image back:

You can see the cut off of the artery near the top, just below that tortuous vessel.

He wrote:

OMI it was. Large diagonal. Now opened.

Dr. Smith—you’ll change MI care, if you haven’t already. I’m changed.

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MY Comment, by KEN GRAUER, MD (1/18/2025):

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It's not often that we see a clinical entity for which it seems that the patient "read the textbook" before the ECG was recorded. By this, I mean that most of the time with well described entities (ie, Brugada patterns, repolarization variants, “shark fin” ST deviations, conduction defects, etc.) — there are a variety of possible ECG patterns that often manifest differences in some way from the textbook description.

• In contrast — Today’s initial ECG (as per Dr. Smith) is clearly diagnostic of an acute OMI that at the stage shown in the BOTTOM tracing in Figure-1, very clearly suggests a “culprit” artery in the 1st or 2nd Diagonal Branch of the LAD.
• As per the schematic picture at the top of Figure-1 — the South African Flag Sign is present in a patient with new CP (Chest Pain) when there is: i) ST elevation in leads I, aVL and V2; — ii) Reciprocal ST depression in lead III (ST depression is also often seen to a lesser degree in neighboring inferior leads II and aVF); — and, iii) No ST elevation in any chest leads except for lead V2 (The principal leads with ST elevation or depression are highlighted in GREEN in Figure-1 — following the distribution of the S. African Flag).

The TOP ECG in Figure-1 is from the April 8, 2022 post in Dr. Smith's ECG Blog — and illustrates the above noted findings of the S. African Flag Sign (ie, ST elevation in leads I,aVL,V2 — reciprocal ST depression in lead III ).

• PEARL #1: As per Dr. Smith — Sometimes acute proximal LAD OMI will initially look like a Diagonal Branch OMI — because ST elevation may initially be limited to lead V2, and only later be seen in leads V1,V3,V4. A tincture of time and serial ECGs will usually clarify the situation.

• PEARL #2: The clinical significance of being aware of a Diagonal Branch “culprit” — is that: i) Since only 1 chest lead shows ST elevation (ie, lead V2) — this pattern will not “fit” the definition of a STEMI, because only 1 chest lead shows ST elevation (and the definition of an anterior STEMI requires 2 contiguous chest leads to show ST elevation); and, ii) Recognizing the S. African Flag Sign alerts the angiographer where to look for the "culprit" artery. We have seen cases in which a capable angiographer initially missed the cath finding of Diagonal Branch occlusion — BUT — seeing this ECG pattern conveyed the need for another LOOK at the cath film, with focus on the expected area for Diagonal Branch takeoff then revealing subtle-but-complete occlusion in one of the Diagonals.

QUESTION:

• How does today's initial ECG differ from the TOP tracing in Figure-1?

Figure-1: The South African Flag Sign — with comparison of the ECG from the April 8, 2022 post — with today's initial ECG.

Comparison between the 2 ECGs in Figure-1:

Both tracings in Figure-1 are consistent with the S. African Flag sign — in that the leads with the most prominent ST-T wave changes are leads I,III,aVL and V2 — which correspond to the arrangement of GREEN coloring in the horizontal "Y" of the South African Flag.

• It is difficult to date the onset of the MI in today's case because this patient never had CP — yet the initial Troponin was markedly elevated.
• The principal difference in the interpretation of the 2 tracings in Figure-1 — is that in addition to ST elevation in leads I,aVL,V2 with ST depression in lead III — there are now reperfusion T waves in ECG #1 (RED arrows indicating T wave inversion in leads I,aVL,V2 — and peaking of the terminal T wave in lead III. This suggests that acute occlusion of the 1st Diagonal occurred some time before this ECG was recorded — and that there has now been some spontaneous reperfusion.
• "Take-Home" — Remember the picture highlighted within the GREEN rectangles in Figure-1.