Thursday, February 23, 2012

Reciprocal ST depression in II, III, aVF. What is the diagnosis?

A colleague approached me with this ECG of a middle aged male with this ECG; my colleague was worried about acute ischemia.  There was no old ECG for comparison.

There is STE in V1-V3, with preceding deep QS-waves, and some T-wave inversion in V3.  This is basically diagnostic of anterior LV aneurysm.  But there is also ST depression in II, III, and aVF, suggestive of reciprocity from high lateral ST elevation, and one can imagine a bit of ST elevation in aVL.  What is going on?  Answer below. 


Lead aVL also has a Q-wave, so there is an old lateral MI.  Put this together with the anterior LV aneurysm, and the fact that many (old or acute) anterior MIs are due to an occlusion of the proximal LAD, with involvement of the lateral wall (and thus with reciprocal ST depression in II, III, and aVF), and it becomes apparent that this is probably part of his LV aneurysm.  LV aneurysm, just like acute STEMI, may have reciprocal ST depression.  In this case, the old high lateral MI manifests as chronic reciprocal ST depression in II, III, and aVF.

His echo confirmed dyskinesis and myocardial thinning diagnostic of LV aneurysm.  The troponin was negative.


  1. Hey Dr. Smith,

    I've noticed. Alot of these anterior LV aneurysm ecgs ( from multiple LV aneurysm posts on your blog since 2008) has a qRs pattern with twi in the lateral leads ( 1 & aVL ) kinda like a LAFB pattern. Is this part of the anterior anueurysm complex or due to ischaemia from the old M.I. . Was hoping you can shed some light on this.

    Thank you for all your great cases, really appreciated.

    1. Saif,
      this is part of the aneurysm, which is due to old MI.
      No acute ischemia.
      Does that answer?


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