APCU25CR6 The aslanger with left fascicular ventricular tachycardia

Introduction Occlusion myocardial infarction is an acute coronary event which the culprit coronary artery can be anticipated on the electrocardiogram (ECG). Here, we describe a case of Aslanger in an elderly lady.Case Presentation 84 years old lady with ischemic heart disease, dyslipidemia, and hypertension presents with chest pain associated with diaphoresis, palpitation, and shortness of breath. Her heart rate and blood pressure were 160 beats/min and 80/50mmHg respectively. Systemic examination was unremarkable. ECG demonstrated regular narrow complex tachycardia, RBBB, with left axis deviation consistent with left posterior fascicular tachycardia which was aborted by synchronized electrical cardioversion. Following successful cardioversion, the arrhythmia recurred and successfully reverted by intravenous Verapamil 5mg. ECG demonstrated sinus rhythm with persistent 1mm ST elevation on lead III, V1, and V2 (V1 is higher than V2), and ST depression on V4-V6 consistent with Aslanger pattern. Troponin was elevated at 616. Coronary angiogram demonstrated dominant LCX with ISR of 70-80% from mid to distal segments, CTO at proximal RCA, and 50% stenosis of proximal LAD. Angioplasty was done to the LCX using DCB sized 2.75 x40mm. She was safely discharged following the inpatient treatment.Discussion NSTEMI describes the presence of myocardial and/or subendocardial infarction resulting from incomplete thrombotic occlusion of the coronary artery. Rupture or erosion of an unstable atherosclerotic plaque is the precursor. OMI represents a situation of incomplete coronary occlusion with sparse collateral circulation, with which infarction is imminent without early reperfusion. Aslanger et al described the ECG pattern represents involvement of left circumflex or RCA as the culprit lesion. The pattern features subtle ST elevation on lead III accompanied by ST depression over V4-V6 with a terminally positive T wave. ST segment on V1 is higher compared to V2. Acute occlusion is imminent if revascularization is not performed. Fascicular tachycardia has been widely reported in patients without structural heart disease. In this case, a significant acute coronary artery disease triggered the arrhythmia. This owes to an injury of the Purkinje system that renders it susceptible to being a substrate for a reentry circuit.Conclusion Aslanger pattern represents a warning sign of imminent acute coronary occlusion that requires immediate revascularization.