Occlusions Over Elevations

Abstract

Background: Acute myocardial infarction (AMI) continues to represent a significant global health issue. While standard ST elevation myocardial infarction (STEMI) criteria guide urgent reperfusion therapy, these benchmarks may fail to identify a considerable subset of acute coronary occlusions (ACO), resulting in delayed intervention. The occlusion myocardial infarction (OMI) paradigm emphasizes electrocardiographic (ECG) findings that suggest complete coronary occlusion, even when classic ST elevation is absent. [1–4]

Objectives: This report reviews three cases presenting with atypical ECG findings—the Aslanger pattern, South African flag sign (SAFS), and de Winter pattern—and correlates these with angiographic anatomy to underscore their implications for expedited reperfusion therapy. [2–6]

Methods: A retrospective descriptive analysis was conducted (January–March 2024), focusing on adult males presenting with atypical symptoms and STEMI equivalent ECGs. Data collected included presentation timelines, biomarkers, point-of-care ultrasound (POCUS), detailed coronary angiography (culprit vessel, lesion severity, collateral circulation, TIMI flow), interventions, and outcomes. A focused literature review (2015–2025) was also performed to contextualize the ECG-angiographic relationships and management approaches. [1–6]
Findings: Case 1 (Aslanger pattern) demonstrated triple vessel disease with critical LAD and RCA lesions. Case 2 South African flag sign (SAFS) exhibited complete D1 occlusion and severe LCx stenosis. Case 3 (de Winter) had >90% proximal LAD stenosis with poor collateralization. Interventions included percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). All patients were discharged in stable condition.

Conclusion: High-risk, non-ST elevation ECG patterns can localize culprit coronary lesions and should prompt emergent reperfusion strategies comparable to STEMI protocols. Systematic adoption of the OMI framework may reduce diagnostic gaps and facilitate timely, life-saving therapy. [3–6]