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High lateral myocardial infarction. (A) ECG with ST-segment elevation in leads I, aVL, and V2 with ST-depression in leads III and aVF. (B) Flag of South Africa superimposed on ECG, showing the characteristic pattern (arrows). (C) Coronary angiography with occlusion of the first diagonal vessel and thrombus with TIMI grade 2 flow (arrows).

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A high lateral myocardial infarction (HLMI) can often be missed due to noncontiguous ST elevation on the electrocardiogram (ECG) [1]. The pattern of ST-segment elevation in lead I, aVL, and V2 with ST-segment depression in lead III is considered a sign of acute occlusion of the D1 branch of the left anterior descending coronary or HLMI, also known as the South African Flag sign [1–3], where the pattern follows the green stripe of this flag, like our case (Fig. 1B). The D1 occlusion results in a projection of the ST-segment vector toward I, aVL, and V2 and away from III and aVF [1]. Identifying ischemic ECG changes early is crucial for timely revascularization and limiting left ventricular dysfunction.

Correspondence address: Department of Cardiology, Hospital Regional 1° de Octubre ISSSTE. Instituto Politécnico Nacional 1669, Gustavo A. Madero, 07760, Mexico City, Mexico. Tel: 443-206-2240. E-mail: martin.alanis.n@gmail.com

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A 80-year-old woman with type 2 diabetes and hypertension presented to the emergency department with acute chest pain. High-sensitivity Troponin I level was 9045 ng/ml (reference value, <19 ng/ml). The electrocardiogram (ECG) demonstrated a complete right bundle branch block as well as ST-segment elevation in leads I, aVL, and V2 with ST-depression in lead III (Fig. 1A), aligned with the South African Flag (Fig. 1B). Transthoracic echocardiography showed only anterior wall hypokinesia and a LVEF of 56%. Emergency coronary angiography revealed occlusion of the first diagonal (D1) vessel and thrombus with TIMI grade 2 flow (Fig. 1C); stent placement was not possible as the vessel was <2 mm in diameter, so an intravenous antiplatelet treatment was administered. The patient’s clinical course was uneventful, and she was discharged symptom-free with medical treatment for secondary prevention.

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