EXTRA COPY — ECG Blog #553: What Happened? — EXTRA COPY —

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Figure-1: The initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio).

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Figure-2: XXXX

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Acknowledgment: My appreciation to Kashif Aleem (from Lahore, Pakistan) for allowing me to use this case and these tracings. 

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Kashif Aleem <rock2hawk@gmail.com>  (on Feb. 10, 2026)

You can address me as 

Kashif Aleem — PIC Lahore, Pakistan. (from Lahore, Pakistan)

 

Hi, I hope this email finds you well. 

I'd really appreciate your input on this one which will help many of my colleagues understand this ecg pattern...

76 years old female with Typical chest pain lasting 2 hours which settled accompanied by unsettling st elevations. 

 

What could be the culprit vessel and what territory infarct/STEMI it can be labeled for documentation purpose. 

I take it as significant and mostly LMCA significant disease. 

I'll follow up on angiogram and share when available. 

Thanking you in advance! 

Stay blessed. 

MY REPLY:

Hi. I agree with you — I strongly suspect this is one of those rare cases of acute LMain occlusion in which the patient survives long enough to do the ECG.

 

I refer you to the December 18, 2025 post in Dr. Smith’s ECG Blog. Check out my comment at the bottom of the page — in which I updated Dr. Smith’s collection, now of 9 cases of documented acute LMain occlusion — as to what you might see on the ECG of a patient with acute LMain occlusion.

 

In a word — you might see ANYTHING! Simply because you have multiple different vectors of ST elevation from varied contributions of all major coronary arteries. Some give ST elevation vectors — other give reciprocal ST depression — and impossible to predict which of these multiple vectors will dominate with ST elevation not cancelled out by opposing ST depression …

In your case — we see marked ST elevation in the antero-lateral area, with reciprocal ST dep in the inferior leads.

 

Hopefully your patient survives.

 

With your permission — I would definitely want to publish an ECG Blog of your case once you have cardiac cath result.

• May I have your permission to publish this case?
• I would be glad to acknowledge you — Please confirm how you would want your name to read = Kashif Aleem? — I also like to add the city and country from where you are from — OR — your contribution could be anonymous. JUST LET ME KNOW.

BEST — Ken

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KASHIF REPLY:

I'd try my best to trace her angiogram. 

I was interested in explanation of these aberrant vectors. Especially st elevation lead 2. Broadly, we have predominant st elevation in left sided leads and st depression in right sided vectors. 

I also acknowledge that I have seen such cases in which this pattern transiently appears like during stress testing and signifies Supply demand mismatch of significant LMCA lesion rather than total occlusion. 

Our patient was hemodynamically stable and chest pain free when presented to our setup. ECG changes and pain had settled completely. Cath operators didn't oblige our request for angiogram on priority basis. 

 

Yeah I would definitely want others to learn from this case...

You can address me as 

Kashif Aleem 

PIC Lahore, Pakistan. 

 

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MY REPLY:

Thanks for your reply.

 

Hard to imagine WHY the interventionists decided not to promptly catheterize this patient ==> this is a KEY factor for others to learn form. The process of acute coronary occlusion is often marked by intermittent “spontaneous reperfusion” of the “culprit” artery, which in this case, most probably is the LMain coronary artery.

What spontaneously reopens — may just as easily (and at any time) spontaneously reclose — and given likely LMain location, this patient would be a high risk of VFib and dying at that time.

• The fact that this patient’s CP resolved and “his ECG changes settled” at that time is telling us that his acute occlusion did spontaneously open. But this patient is at very high risk of spontaneous reclosure that may occur at any time.

 

As to “explaining” the reason for the location of findings — I think Dr. Smith’s collection of 9 cases (that I put together in the attached table) tells the story. The KEY points are:

• We have NO IDEA as to what the “culprit’ artery looked like at the time that cath was done! (ie, We know there was spontaneous reopening shortly after because CP resolved and the ST elevation was much less) —  so we just don’t know if the culprit artery was completely or partially closed at that time …
• There could have been subtotal (but not complete) LMain occlusion with some unpredictable pattern of collateral flow.
• Instead of LMain occlusion — there could be underlying multivessel disease with occlusion of one or more of the major arteries (ie, acute occlusion of the proximal LAD and LCx …).

 

All I know is that we see a huge vector of anterolateral ST elevation here with reciprocal ST dep in “right-sided” areas ( = leads IIII, aVR and V1).

 

Would be GREAT if you could get a copy of that ECG at the time CP resolved and the ECG improved. The fact that operators decided not to immediately cath the patient because CP resolved and the ECG improved is the KEY learning point.

 

Hopefully the patient survives …

 

Ken

 

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Thank you Kashif.

 

I’ll await cath results from you. I’ll try to publish this within a month or so after I receive cath results (I have a few other cases to go before — and it also will be good to give this a little time before I publish the case).

• Let me know how much time passes until cardiac cath is done ...

I will acknowledge you = Kashif Aleem (from PIC Lahore, Pakistan) — and I will let you know once the case is published.

 

There is a lot for others to learn from this case! — Ken