The convergence of diversity: an ECG sign of high lateral coronary occlusion

A 44-year-old man presented with chest pain and an unusual pattern of ST-elevation in leads aVL and V2, and ST-depression in leads II, III and aVF on electrocardiogram (ECG). Artificial intelligence (AI)-augmented ECG interpretation reported the abnormality as indicative of occlusive myocardial infarction (OMI) and highlighted the abnormal leads in the pattern that was recognised to be that of the South African flag. This previously reported pattern is associated with acute occlusion of the intermediate or high diagonal coronary arteries, which was then confirmed on coronary angiography, but only when an extreme left anterior oblique (LAO) caudal view was used. The intermediate artery was successfully treated with percutaneous coronary intervention (PCI). It is our experience, like that of Louis Pasteur, that chance appears to favour the prepared mind. This case highlights the importance of being prepared by recognising non-typical ECG patterns associated with acute coronary occlusion, and being aware of which vessel is likely to be occluded. This demonstrates the utility that AI-augmented ECG interpretation can bring to cardiologists to refine patient management.