The paper argues that the OMI paradigm should replace STEMI/NSTEMI to capture patients with coronary occlusion lacking classic ST elevation, and presents a case in which prompt recognition of the evolving 'South Africa Flag' ECG pattern identified OMI in the setting of a possible allergic reaction, possibly due to Kounis syndrome (unconfirmed).
The STEMI/NSTEMI paradigm is being supplanted by the Occlusion Myocardial Infarction (OMI) paradigm.
Prompt recognition of evolving 'South Africa Flag' ECG changes was the first 'needle in the haystack' in the reported case of OMI.
Kounis syndrome is proposed as a second, possible but unconfirmed, contributor to the case presentation.
This paper describes a case report and short review about heart attacks that are caused by a fully blocked heart artery but don't show the classic ECG sign of 'ST elevation.' The author argues that the older way of sorting heart attacks (STEMI vs. NSTEMI) can miss these patients, and that a newer approach, called occlusion myocardial infarction (OMI), better identifies people who need prompt procedures to open the artery, ideally within 2 hours. In the case presented, clinicians recognized an evolving ECG pattern called the 'South Africa Flag' sign in a patient who possibly had an allergic reaction. The author suggests the heart attack may have been related to Kounis syndrome, in which an allergic reaction triggers heart problems, but this link was not confirmed. This research suggests that careful ECG reading, including attention to subtle patterns, may help emergency clinicians spot blocked arteries that standard criteria might miss. Because it is a single case report, it cannot show how common these patterns are or prove that allergy caused the heart attack.
Bowman A. (2026). Two Needles in a Haystack: Acute Occlusion Myocardial Infarction Presenting With South Africa Flag Sign Possibly Due to Kounis Syndrome-A Review and Case Report.. Advanced emergency nursing journal. https://doi.org/10.1097/TME.0000000000000652