CONGRESS ABSTRACT

A 66-year-old woman came to the emergency room suffering from chest pain. At the interview she reported brief episodes of retrosternal pain with radiation to the left shoulder for approximately 3 day. The blood chemistry tests revealed pathological troponin kinetics (first: usTnT 29 pg/ml, after 2 hours: 42 pg/ml). The medical history indicated a family history of ischemic heart disease, systemic arterial hypertension, dyslipidemia, type 2 diabetes mellitus, active smoking. The first ECG performed on admission showed a slight elevation of the ST segment in V1 and aVR (< 1 mm) and mirror depression in V4-5-6, DI-DII and aVL, and the second ECG performed at 2 hours which showed isolated ST segment elevation in DIII (< 1 mm) and mirrored ST segment depression in V2, aVL and DI. At that time, the patient described herself as asymptomatic due to angor. At that point, the cardiologist found himself in the situation of having to decide whether to perform the angiographic study immediately or defer it for 24 hours. The picture indicated an acute myocardial infarction, but the ECG changes were decidedly atypical and did not fully satisfy the definition of ST-segment elevation myocardial infarction (STEMI). The ECGs previously described fall into the so-called Aslanger pattern; this pattern, although not satisfying the classic STEMI criteria, represents patients with acute inferior myocardial infarction who are predisposed to a rapid deterioration of hemodynamic compensation and for this reason an urgent hemodynamic study is indicated. The cardiologist on duty therefore alerted the Hemodynamics room of the HUB center where coronary angiography was performed which showed multiple severe stenosis in series from the ostium to the middle tract of the anterior descending artery, severe stenosis of the circumflex-obtuse marginal bifurcation, thrombotic occlusion of the distal right coronary artery (dominant), with initial spontaneous reperfusion of the posterolateral branch. Emergency angiographic study must be limited to cases in which ST elevation > 1 mm occurs in 2 or more contiguous leads and to cases of hemodynamic and electrical instability. However, there are cases, like the one described, in which an extremely serious coronary picture appears without a clear picture of ST elevation. Patterns indicative of acute coronary occlusion without ST elevation (eg.Aslanger)must always be looked for if such clinical suspicion exists and the ECG is not conclusive for STEMI