Friday, December 19, 2014

Beware confusing the diagnosis of posterior STEMI by using posterior leads...

Or at least understand their limitations!!


This patient had chest pain and this ECG:
There is no significant ST elevation. But there is ischemic ST depression in V2-V6.  It is maximal in V3 and V4, which represents posterior STEMI until proven otherwise.

(This can be due to subendocardial ischemia, but less likely.  Most subendocardial ischemia is diffuse, with the ST depression vector pointing towards the apex of the heart (II, V5) and thus has maximal ST depression out in V5 and V6.  

The ST elevation vector is clearly away from V3 and V4, towards the posterior wall.  If you put posterior leads on, you MUST get posterior ST elevation.  HOWEVER, it may be of very small magnitude and thus is may be a false negative.

Posterior leads were applied:
V3 is misplaced here, so ignore it.  Notice there is some ST elevation in V7-V9, but it is minimal.  It does not even meet the "criteria" of 0.5 mm in posterior leads.  V2 has the same ST depression in had on the first ECG, confirming that the artery is still closed.

So this gives a false negative.  Posterior leads lead you astray.  The voltage is so small that you might be dissuaded from your diagnosis of posterior MI.

This was indeed a circuflex occlusion with a posterior wall motion abnormality.




So when should you use posterior leads?

There is some literature showing that some posterior MI show up only on anterior precordial leads as ST depression, and some show only on posterior leads.

I think some of this is due to timing.  Arteries open and close and if you don't record the ECGs simultaneous, then you might be recording two different conditions of ischemia.

It may be useful to record posterior leads in a patient in whom you are convinced has an MI but has no significant abnormalities on the standard 12-lead. 

9 comments:

  1. I have been through a situation like this.And when the posterior leads showed no STe,I thought I was wrong.Thanks for this tip.

    ReplyDelete
    Replies
    1. Yes, and it is contrary to much standard wisdom on the topic, no?

      Delete
  2. "I think some of this is due to timing" - I like that line.

    ReplyDelete
  3. I assume that you are surveying how others think in such situation ..But I don't have much experience..I am an young resident..Please consider this as a private message..Thanks for being helpful.

    ReplyDelete
    Replies
    1. I'm saying it as someone who has read the literature on this for the last 24 years and has a huge amount of experience.

      Delete
  4. Sir,I know well that you are an excellent expertise in your field and I access your blog many times daily..But I understood that you meant to reveal how doctors think in such situation so you can help others by correcting their thoughts..Pardon me as English isn't my mother tongue so I didn't express myself correctly.Thanks for being helpful.

    ReplyDelete
  5. Steve, what about aVR in the presenting ECG, it appeared to have 2mm STE at the j point?

    ReplyDelete
    Replies
    1. Good observation. And, as always with ST elevation in aVR, there is ST depression in I and II. The ST elevation vector is not only posterior, but a bit to the right. This probably indicates some STEMI of the posteromedial wall. It is entirely different from the common reason for ST elevation in aVR: leftward and inferior ST depression vector with a reciprocal ST elevation vector towards aVR.

      Delete
    2. This comment has been removed by the author.

      Delete

Recommended Resources