ECG Case 014

Middle aged patient presenting with central chest pain. What does the ECG show?

TOP 100 ECG QUIZ LITFL 014

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Evidence of inferolateral STEMI

  • ST elevation in the inferior leads (II, III, aVF)
  • ST elevation in the lateral leads (I, V5, V6)

Evidence of posterior STEMI

  • Horizontal ST depression in V1-4 (maximal in V2-3)
  • Dominant R wave in V2 (R/S ratio > 1)
  • Upright T wave in V2

This pattern of infero-postero-lateral STEMI is most likely caused by occlusion of a dominant left circumflex artery.


CLINICAL PEARLS

Tips for spotting posterior infarction

Look specifically at lead V2 for the combination of

  • Horizontal ST depression.
  • Tall, broad R wave (>30ms wide, R/S ratio > 1) — this is a Q-wave equivalent.
  • Upright T wave — particularly the terminal portion of the T wave.

One common trick is to turn the ECG over, hold it up to the light and look through it from behind. This inverts lead V2, which then takes on the appearance of a classic STEMI.

Posterior AMI flip STEMI ST Elevation

Look for evidence of posterior involvement in any patient with an inferior or lateral STEMI.

Sometimes it can be difficult to determine whether ST depression in V2-3 is due to posterior STEMI or simply subendocardial ischaemia affecting the anteroseptal wall. The diagnosis can be confirmed by recording posterior leads V7-9.


TOP 100 ECG SERIES


Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

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