Case Report
THE SHARK FIN PATTERN AS A PREDICTOR OF SUDDEN CARDIAC DEATH IN
ISCHEMIC AND NON-ISCHEMIC PATIENTS
Moza Guyanto1.
Fredy Tandri2.
Alexander Edo Tondas3,4 * Cardiovascular Medicine Resident.
Department of Cardiology and Vascular Medicine.
Universitas Indonesia.
Jakarta Cardiovascular Medicine Resident.
Department of Cardiology and Vascular Medicine.
Universitas Diponegoro.
Semarang Faculty of Medicine.
Universitas Indo Global Mandiri.
Palembang Department of Cardiology and Vascular Medicine.
Mohammad Hoesin General Hospital.
Palembang email penulis korespondensi: alexanderedo@uigm.
ABSTRACT
Background: The Aushark finAy pattern, also known as a triangular QRSAeSTAeT waveform, is a distinctive electrocardiographic (ECG) manifestation of ST-segment elevation myocardial infarction (STEMI).
It is characterized by a triangular morphology resulting from the fusion of the QRS complex.
ST segment, and T wave.
Case Illustration: We present a case series of three patients exhibiting the Aushark finAy ECG pattern.
Two patients were adults with a history of ischemic heart disease, while one was a 19-year-old male with no significant past medical history.
One adult patient was treated with thrombolytic therapy, and the other underwent percutaneous coronary intervention.
One of the adult patients and the young patient developed malignant arrhythmias and subsequently experienced sudden cardiac death.
Conclusion: The Aushark finAy ECG pattern is associated with a poor in-hospital prognosis, including an increased risk of ventricular fibrillation (VF) and sudden cardiac death (SCD) in both ischemic and non-ischemic patients.
When this pattern is identified, prompt and aggressive management is essential to improve patient survival.
Keywords: Shark fin.
Ventricular fibrillation.
Cardiogenic shock: sudden cardiac death
INTRODUCTION
The ST-segment elevation myocardial infarction (STEMI) is a very serious type of acute coronary syndrome or heart attack in which transmural myocardial ischemia due to occlusion of the coronary artery results in myocardial injury or necrosis.
This electrocardiographic hallmark which typically characterized by J-point elevation was first described in 1920 by Pardee and has been known for a century.
This pattern may have different morphology, duration, and polarity of the T wave depending on the location, severity, and duration of the ischemia.
The most notorious of STEMI patterns is the tombstoning which showed a domed ST-segment configuration resembling a Previous studies reported a specific Aushark finAy pattern characterized by a triangular giant wave .
mplitude > 1 mV) resulting from the fusion of QRS complex, steep down-sloping ST-segment, and T wave with positive polarity.
1 The Aushark finAy pattern is a relatively new term.
it was previously referred to as lambda-like pattern and giant R wave but the terminology triangular QRS-ST-T waveform has been suggested.
1 The Aushark finAy pattern was associated with malignant in-hospital prognosis, increased risk of ventricular fibrillation (VF) on admission, the involvement of left main coronary artery (LMCA), and sudden cardiac death (SDC) due to cardiogenic shock in STEMI patients and rare cases of Takotsubo cardiomyopathy (Cipriani, 2018.
Tarantino, 2.
We present three cases of patients with the Aushark finAy ECG pattern to warn us that this ECG patten can have dangerous outcome in both ischemic and non-ischemic patient if not recognized and treated promptly.
CASE ILLUSTRATION
Case 1 A 48-year-old female patient complained of chest discomfort, shortness of breath, and dizziness before being admitted to the emergency room.
She has a past medical history of hypertension, diabetes, and ischemic stroke 8 years ago.
On admission, she was unconscious, without arterial pulse and her admission ECG showed VF.
CPR and defibrillation were performed and ROSC was achieved Endotracheal intubation was carried out, and 12-lead ECG showed Triangular QRS-ST-T waveform (Aushark finAy patter.
at inferior leads.
Laboratory findings showed leukocytosis .
7*103/L), elevated liver enzyme (SGOT 340 U/L.
SGPT 314 U/L), decreased kidney function (Cr 1.
6 mg/dl, eGFR 37.
57ml/min/1.
73 m.
, hyperglycemia .
mg/dL), and normal sodium .
mmol/L) and potassium .
5 mmol/L).
Coronary angiography revealed 3 vessel disease (VD) with total occlusion of proximal RCA, 60-80% stenosis of proximal LCX, diffuse 60-90% stenosis of proximal to distal LAD, and diffuse 80-90% stenosis of Ramus Intermedius.
Primary PCI was performed, and a drug-eluting stent (DES) was implanted on the culprit lesion of RCA.
The patient has recurrent VF during the procedure, hence 200-joule defibrillation was done about 7 times, and an IV drip of amiodarone and norepinephrine was also administered.
After the procedure, the patient was still unconscious and unresponsive with hyperglycemia .
mg/dL).
Blood gas analysis showed slight compensated respiratory alkalosis .
H 7.
47, pCO2 27.
HCO3 20.
with good arterial oxygenation .
O2 99.
The patient was given aspirin, ticagrelor, statin, and amiodarone, while the insulin drip was administered to lower her glucose level.
After two days of treatment, the patient showed no sign of improvement and her condition kept deteriorating.
Unfortunately, the patient went to cardiac arrest.
CPR failed to revive her, and was pronounced dead on the third day of Figure 1.
ECG after ROSC showed the Aushark finAy pattern on inferior leads.
Case 2 A 19-year-old male was admitted to the Emergency Department due to seizure about 1 hour His past medical and family history were unremarkable.
At presentation, he was unconscious without arterial pulse, and the monitor showed VF.
CPR and defibrillation about seven times terminated VF.
ROSC was achieved with blood pressure 96/53 and heart rate 88bpm.
Tracheal intubation, intravenous fluid resuscitation, and vasopressor were attempted.
Later, 12-lead ECG showed wide complex QRS with positive dominant R wave resembling Aushark finAy at lead aVR.
Laboratory showed normal troponin I .
and potassium .
Blood gas analysis showed metabolic acidosis .
H:7.
HCO3:11.
pCO2:39.
with arterial hypoxemia .
O2:.
Unfortunately, the patientAos rhythm went asystole and CPR failed to save him.
Figure 2.
12 Leads ECG after ROSC Achieved showed the Aushark finAy pattern on aVR.
Case 3 A 56-year-old-man was presented to the emergency department with epigastric pain, diaphoresis, and lightheadedness since 3 hours ago.
He has a past medical history of hypertension, diabetes, and stroke that occurred 2 years ago.
His physical examination showed blood pressure of 80/40 mmHg and heart rate of 70 bpm.
A 12-lead electrocardiogram revealed ST-segment elevation at II, i, aVF and Total Atrioventricular block.
He was found to have severe hyperkalemia (K 7.
1mEq/.
, decreased kidney function (Cr 2.
7 mg/dl, eGFR 26.
15ml/min/1.
73 m.
, mild anemia (Hb 12.
4g/d.
, leukocytosis .
3*103/L), mild hyponatremia .
mEq/L) and hyperglycemia .
mg/dL).
A loading dose of aspirin and clopidogrel with nitrate for relieving ischemic discomfort was Later, the reperfusion strategy for the patient was assessed.
He underwent thrombolytic using streptokinase 1,5 million units as there werenAot any absolute contraindications.
The ECG before thrombolytic showed an evolution of the ST-T segment with Triangular QRS-ST-T wave (Aushark finAy patter.
appeared on the inferior leads.
Right Bundle Branch Block (R.
and first degree AV Figure 3.
ECG at presentation (A) and before thrombolysis which showed the Aushark finAy pattern on the inferior leads (B) There wasnAot any complication following thrombolytic therapy and the patient was monitored in the High Care Unit.
More than 50% resolution of ST-segment elevation and terminal T wave inversion at inferior lead suggest the success of thrombolytic therapy.
Because of renal impairment, oral hypoglycemic medications were changed to insulin therapy and Enoxaparin was preferred with dose adjustment.
Kalium level was normalized to 4.
2 mEg/l after using Calcium Polystyrene Sulphonate.
Other standard medical managements were also given .
itroglycerin, aspirin, clopidogrel, atorvastatin.
Kidmin solution, laxative, benzodiazepine, antibiotic, and proton pump The patient was doing well and discharged from the hospital on the fifth day after There werenAot any malignant arrhythmias events that occurred during hospitalization.
Figure 4.
ECG after Thrombolytic Table 1.
Clinical Characteristic of the three patients with Aushark finAy ECG pattern.
DISCUSSION