The South African Flag Sign: An Electrocardiographic Flag for All Coronary Territories?

The South African flag sign (SAFS) is an acute, dynamic electrocardiographic (ECG) finding typically associated with first diagonal (D1) artery occlusion. We report the case of a 47-year-old woman who exhibited this pattern but subsequently revealed the dreaded "widow-maker" lesion (100% occluded proximal left anterior descending [LAD] artery) and severe multivessel disease (90% stenosis of the posterior left ventricular [PLV] artery and 80% stenosis of the left circumflex artery [LCx]).