It is a good idea to do a right-sided ECG in all inferior STEMI cases, as RV involvement can change the management approach. This results in part of the inferior wall being supplied by the LAD, as well. This patient had an acute mid-LAD thrombus after the septal branches and after the first major diagonal branch.This example below actually does not meet criteria for an anterior MI based on the J point in V3 or V4, but it does in the septal leads V1 and V2. Air versus oxygen in ST-Segment-Elevation Myocardial Infarction. It’s just not good.

This is a good example to quickly point out something else. Isolated ST depression in V1 V2 V3 .It almost always indicate isolated posterior STEMI. Read the Sure, all of these anterior MIs technically have J point elevation, and we already know that the actual definition of a STEMI from the ACC/AHA is based on the J point. (Vertical vs Horizontal)Posterior surface is now referred to as infero-posteriorThe posterior aspect of heart contains essentially the venous channels and the atrium (LA in particular)pulmonary veins and coronary sinus. However, as you can see, sometimes it is quite obvious that an anterior STEMI is present, and sometimes it is not. Recall that a right bundle branch block does not stop us from detecting a STEMI on an ECG. Here are some examples of what isolated J point elevation looks like.If you looked quickly, you may miss this one. The ST segment elevation barely reaches 5 mm in V3, and there is a bit of ST segment elevation laterally in lead V5 and V6. Recall that the J point is where we need to measure the elevation from baseline, and the baseline is always the TP segment (between the T wave and the P wave).Below is another example of tombstoning with a slightly different shape. STEMI typically defined by: ≥1 mm (0.1 mV) ST segment elevation in limb leads ≥ 2 mm ST segment elevation in precordial leads; Findings present in at least 2 anatomically contiguous leads; Several variations from the classic STEMI ECG changes are similarly concerning and considered 'STEMI equivalent' STEMI Equivalents Posterior MI Image from: ABC of clinical electrocardiography - Acute myocardial infarction - Part 1 Electrode positions: V7: posterior axillary line, lead V8: midscapular, V9: paraspinal See also: Pure (Isolated) Posterior STEMI - Not so rare, but often ignored! You can also consider using modified leads V7, V8, and V9. While conduction disorders and ischemic mitral regurgitation   can occur  significantly.Also read ,  Why thrombolysis is contraindicated in UA/NSTEMI ? In an anterior MI that shows “tombstoning,” there is frequently 4 to 6 millimeter of ST segment elevation. Missing a ST segment elevation MI on the ECG can lead to bad patient outcomes.

. There is no inferior involvement here. Below is an example where there is J point elevation, but it does not quite tombstone and does not really have eye-catching ST segment elevation.This pattern is less common during an acute MI. Oh, my!We will get to the examples soon, but first we need to understand some more basics of anterior MIs.If the thrombus is in the proximal LAD, the septum and lateral walls will often also be involved, in addition to the anterior segments, resulting in ST segment elevation in leads V1 through V6 and perhaps lead I and aVL, as well.When the thrombus is in the mid LAD (after the septal branch), the diagonal branch(es) may or may not be involved.

Now, “high lateral” MIs with ST segment elevation in the limb leads I and aVL can show reciprocal ST segment depression in leads II, III and aVF.Here is some more terminology. Here it is used to emphasise ST elevation is not the only indication for thrombolysis .In posterior MI there is infact ST elevation but it is failed to pick up by standard 12 lead ECG.Isolated ST depression in V1 V2 V3 .It almost always indicate isolated posterior STEMI. The electrocardiogram at presentation showed marked ST-segment depression in leads V(1) to … Both scapula and  para spinal muscles can be a  significant electrical  barrier that can prevent ST elevation from inscribed .In case of doubtful ST elevation in posterior leads , mit is always better to rely on the clinical presentation.Acute chest pain , consistent with ACS and a new onset ST depression >2mm V1 to v3 is a definite indication for thrombolysis .They are closely linked entities .In fact posterior surface of heart is contributed significantly by RV.It almost always localise the lesion to left circumflex artery . Sometimes, it is obvious on the ECG when a posterior MI accompanies an inferior STEMI, but it can also occur all by itself.The ECG criteria to diagnose a posterior MI — treated like a STEMI, even though no real ST segment elevation is apparent — include:Below are some examples including isolated posterior MIs, inferior STEMIs with posterior involvement and a posterior ECG. Get the latest news and education delivered to your inboxGet the latest news and education delivered to your inbox Key 12-Lead Features. What Happens to the Heart?

There is definite elevation of the J point in V2 to V6, at least, and minimal elevation in V1 and V6.

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