Slide 1: What’s your next step? [EKG] (Patient c/o acute chest pain)
Slide 2: Call a STEMI Code! [EKG: did you catch this STE in lead III?]
Slide 3: But– are those the only ST “elevations”? [EKG showing STDs in V1-V3] STD in V1-V3? Think posterior STE! Anterior ST-segment depressions could be reciprocal changes from elevation in the posterior leads!
Slide 4: Your posterior leads show… [EKG with V6-V7 ST elevations] -> it’s also a posterior STEMI
Slide 5: Pro Tip: Worried about a posterior MI? Flip the paper over, hold the EKG to the light, and look at V1-V3. [EKG showing upright 12-lead] [EKG showing inverted 12-lead]
Slide 6: Indications for posterior EKGs. 1. Anterior ST depressions. 2. Chest pain with normal (anterior) EKG findings and clinical suspicion for cardiac pathology. #12LeadThursday throbwack: What’s the most common “electrically silent” MI? 3. Chest pain with prominent precordial R waves (the equivalent of a posterior Q wave)
References
- van Gorselen EO, Verheugt FW, Meursing BT, Oude Ophuis AJ. Posterior myocardial infarction: the dark side of the moon. Neth Heart J. 2007 Jan;15(1):16-21. PMID 17612703.
- Rhee D. Active chest pain. Trop = 5.0. 12 Lead Thursday, Core IM. December 27, 2018. Link.
Tags: cardiology, inferior MI, posterior MI, STEMI
3 comments on “Patient with chest pain, what’s your next step?”
Interesting. There is also a very subtle STE in V6 1which is sometimes present in posterior MI, which actually caught my attention as I was examining the inferior leads. Presumably this is because V6 site right on the border with posterior leads.
Also in the posterior leads panel, is it a typo that the leads are listed as V6, V7, V8 or were there only two leads that moved, i.e. V7 and V8?
Keep posting ECGs please.
You’re correct about the typo. Should say V7, V8, and V9.
On the original 12 lead, very subtle morphological abnormality with the ST segment. It’s a great pickup, and a subtle finding that should prompt more thorough evaluation. That ST segment is the intermediate finding between normal and frank elevations
Interesting – I totally missed that V6. And yes, it should say “V7, 8, 9” sorry about the typo!