ECG Case 039

This ECG shows extensive infero-postero-lateral STEMI with “tombstone” morphology:

• Gross ST elevation in II, III, aVF consistent with inferior infarction.
• Reciprocal ST depression seen in I, aVL.
• ST elevation in V5-6 indicating lateral wall involvement.
• ST depression in V2 is suggestive of associated posterior wall infarction — the morphology is the exact inverse of the ST elevation in the inferior leads.

There are some additional features suggest of right ventricular infarction:

• STE in lead III > lead II.
• Deep ST depression in V2 with an isoelectric ST segment in V1.

This is a huge infarct with a likely poor prognosis. Hypotension may be due to nitrate therapy causing exaggerated preload reduction in the context of RV infarction, or may simply reflect the large infarct size with development of early cardiogenic shock.

Further Reading

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.
• Wiesbauer F. Little Black Book of ECG Secrets. Medmastery PDF