We thank Fiol et al. for their comments on our article. After reviewing the literature cited, we agree that the term high lateral infarction (from the classic Myers classification) is incorrect and should no longer be used. Given the variable blood supply to the mid-lateral segment (and more specifically to echocardiographic segments 12 and 16, which can be supplied by the circumflex artery or the first diagonal artery), we consider that limited anterolateral wall myocardial infarction1 is a more appropriate term.

While it is certainly true that the l and aVL leads are contiguous in the frontal plane, they appear separately in ECG tracings (whether 12-lead or 3 × 4 display formats), leaving them open to misinterpretation by an inexperienced reader.

According to data from the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) Infarction Code Registry,2 a variable, though not insignificant, percentage of patients do not initially meet the criteria for infarction code activation. Resulting delays could potentially increase time to reperfusion depending on the systems in place. As stated by Birnbaum et al.3 and corroborated by Fiol et al.4 first diagonal artery occlusion is one of several ECG patterns that can lead to false negatives. Accordingly, we believe that any finding that could potentially improve early identification of acute coronary syndrome is useful. This includes the South African flag pattern, which in our opinion more than deserves its place, particularly in out-of-hospital settings where 3 × 4 ECG configurations are more common.