Clinical Features of the Aslanger Pattern to Compensate for the Limitation of ST-Elevation Myocardial Infarction (STEMI) Criteria

Abstract

Background: ST-elevation is one of the most valuable electrocardiogram findings to diagnose acute myocardial infarction. However, more than a quarter of acute coronary occlusions are missed by this criterion, causing a delay in revascularization. Therefore, there should be awareness of the limitations of the current criteria and new electrocardiographic findings are required as a diagnostic tool to compensate for them. The Aslanger pattern is a specific electrocardiographic finding in acute inferior myocardial infarction with multivessel disease and allows the detection of inferior myocardial infarction that does not show ST-elevation, leading to rapid revascularization. However, in patients with the Aslanger pattern, the hemodynamic characteristics, such as the rate of shock and the use of mechanical circulatory support, as well as prognostic characteristics such as the in-hospital mortality rate, have not yet been clarified. Methods: In this study, we retrospectively surveyed the current practice on the basis of ST-elevation myocardial infarction (STEMI) criteria in patients with acute coronary artery occlusion presenting with inferior myocardial infarction. We examined the clinical characteristics of the Aslanger pattern. Results: Based on the STEMI criteria, 71.8% (51/72) of patients were diagnosed with STEMI from an acute electrocardiogram, and 28.2% (21/78) were diagnosed with non-STEMI. As expected, ruling out in all acute coronary artery occlusions using STEMI criteria alone was difficult. A total of 48% of patients with non-STEMI had the Aslanger pattern. In addition, 80% of patients with the Aslanger pattern had multivessel disease, 30% had the use of the mechanical circulatory support, and 20% had in-hospital mortality. Conclusion: This study suggests that the Aslanger pattern is useful not only for diagnosis, but also for predicting hemodynamic collapse and a poor prognosis. Therefore, we should share information on Aslanger pattern with other physicians and use this pattern in daily practice.

A patient with acute myocardial infarction with electrocardiogram Aslanger’s pattern

“…In April 2020, Aslanger et al reviewed ECG and angiography in 1000 patients with NSTEMI and 1000 patients without MI, and identified patients with acute inferior occlusive myocardial infarction with concomitant critical stenoses on other coronary arteries presenting a specific ECG pattern : (1) Isolated ST-segment elevation in lead III and no ST-segment elevation in the remaining inferior leads; (2) ST segment depression in lead V4-V6 with positive T wave/terminal vector; (3) ST segment elevation in lead V1 was greater than that in lead V2 [ 1 , 2 ]. In the case of localized inferior-wall injury, the ST vector of inferior myocardial infarction locates the infarct territory and usually points downward and to the right.…”

“…Aslanger’s pattern [ 1 , 2 ] was proposed by Aslanger et al in April 2020 after reviewing 1000 electrograms(ECG) of acute non-ST-segment elevation myocardial infarction (NSTEMI). This ECG pattern includes the following features: (1) Isolated ST-segment elevation in lead III and no ST-segment elevation in the remaining inferior leads; (2) ST segment depression in lead V4-V6 with positive T wave/terminal vector; (3) ST segment elevation in lead V1 was greater than that in lead V2.…”

Nhân Một Trường Hợp Nhồi Máu Cơ Tim Cấp Có Ecg Dạng Aslanger Tại Bệnh Viện Đại Học Y Dược Thành Phố Hồ Chí Minh

“…Một nghiên cứu của tác giả Eiji Miyauchi và cộng sự trên 72 người bệnh tại Nhật về đặc điểm lâm sàng của các người bệnh nhồi máu cơ tim dạng Aslanger được công bố trên tạp chí Cureus năm 2023 cho thấy trong các người bệnh được chẩn đoán NSTEMI, có 48% người bệnh có ECG dạng Aslanger. Trong số này, 80% người bệnh có tổn thương nhiều nhánh mạch vành, 30% người bệnh phải sử dụng dụng cụ hỗ trợ tuần hoàn cơ học, 20% người bệnh tử vong nội viện [9]. Biến đổi tinh tế của đoạn ST trong dạng Aslanger không dễ nhận biết và có thể bị bỏ qua, do đó các bác sĩ lâm sàng phải thật cảnh giác và phân tích kỹ ECG.…”

Além do Paradigma IAMCSST-IAMSSST: Proposta do Instituto Dante Pazzanese para o Diagnóstico de Oclusão Coronariana Aguda

“…Procura por outros sinais de OCA: além de se avaliar a EST, médicos devem estar atentos para identificar outros indicadores eletrocardiográficos que possam sugerir OCA: 54 , 55 EST sutil (< 1mm) é frequentemente vista na OCA, e qualquer EST ≥ 1mm na V2-V4 pode ser normal ou por OCA na ADAE; usar a fórmula de quatro variáveis para diferenciar; 34 ondas T hiperagudas com EST sutil com ou sem EST, 56 sinal de De Winter, 57 , 58 padrão de Aslanger, 36 , 59 , 60 DST em V1-V4 representando alterações recíprocas da parede lateral (V7-V9), 41 distorção terminal do QRS, 33 EST nas derivações inferiores acompanhada por qualquer DST na aVL indicativo de alterações recíprocas a partir da parede anterior média, 39 critério de Sgarbossa modificado por Smith em casos de BRE 47 , 61 ou ritmo estimulado. 48 A presença de qualquer desses sinais necessita reperfusão imediata.…”

“…Looking for other signs of OMI: in addition to assessing for STE, clinicians should be vigilant in identifying other electrocardiographic indicators that may suggest OMI: 54 , 55 Subtle STE < 1 mm is frequently seen in acute OMI, and any STE of ≥ 1 mm in V2-V4 can be either normal or due to LAD artery OMI; use the four-variable formula to differentiate; 34 hyperacute T-waves with subtle STE or without any STE at all, 56 De Winter's sign, 57 , 58 Aslanger's pattern, 36 , 59 , 60 any STD in V1-V4 representing reciprocal changes from lateral wall (V7-V9), 41 terminal QRS distortion, 33 any STE in inferior leads accompanied by any STD in aVL indicative of reciprocal changes from the mid-anterior wall, 39 Smith's modified Sgarbossa criteria in instances of LBBB 47 , 61 or paced rhythm. 48 The presence of any of these signs necessitates immediate reperfusion.…”