———————————E Figure 23.4: Coronary Vasospasm. Electrocardiogram Aand Bare from the same patient. (A) ST elevation in multiple leads (arrows), which may be due to an oc- clusive thrombus or coronary vasospasm. (B) After nitroglycerin was given. The ST segment elevation has completely resolved within min- Utes consistent with coronary vasospasm. Coronary angiography showed smooth walled coronary ar- teries with no occlusive disease,Figure 23.6: (A) HyperacuteT Waves. The initial electrocardiogram (ECG) of a patient presenting with acute onset of chest pain is shown. Tall, hyperacute T waves (arrows) are seen in V, to V, with elevation of the ST segments in V3_z. Note that the hy- peracute T waves are confined to the distribution of the occluded vessel and are usually the first to occur be- fore the ST segments become elevated. Subsequent ECGs are shown in (B-D).(B) ST elevation Myocardial Infarction (MI). This tracing was recorded 15 minutes af- ter the initial ECG. In ad hyperacute T waves, ST elevation has developed in V, to V, (arrows). (continued) A“ es ne ee yt 4 a A pay { a A Wel bey “AAS / Te Ln oo te (AeA ef ie A aCc 1 wa a { woey ah pee ry a i ath aha ‘ e coe tees Aba La fo fe i tv -\4t a Ne a } = Sa a EL EU A ee + ar aw 7 y ath ah hyp ag Tren aol! Na ho ape wow tee lk pry ba pie Figure 23.6: (Continued) (C) ST Elevation MI. The above ECG was recorded approximately 1.5 hours from the initial ECG (see A). The ST segments continued to evolve even after thrombolytic therapy.ST eleva- tion has become more pronounced in V; to Ve and slight elev ‘ST segments is noted in I Hyperacute T waves are inV2to Vs (arrows). (D) ST Elevation MI.ECG recorded 13 days later.QS complexes or decreased amplitude of the r waves are seen in V, to Vs. The ST segments are isoelectric and the T waves are inverted from V5 and leads nd aVL.eS A. Figure 23.7: ST Elevation My- ocardial Infarction. Electrocardiogram (ECG) A was recorded before thrombolytic ther- apy.ST segment elevation is present in UI, aVF, and V4-g (arrows) with ST depression in V;-2.(B) Taken 1 hour after thrombolytic therapy. ST eleva- tion in the inferolateral leads have resolved and inverted T waves are now present in lead Ill, both are signs of successful reperfusion.Figure 23.10: Reciprocal ST Depression. When ST elevation from myocardial ischemia is recorded in any lead, a flip side image is recorded directly opposite the lead.In the above example, ST elevation is recorded in lead Ill (+120°), reciprocal ST depression is also recorded at —60°. Because there is no frontal lead representing —60° lead aVL, which is adjacent to —60°, will exhibit the most pronounced reciprocal change (see Figs.23.11 and 23.12).ECG Changes in ST Elevation MI Figure 23.11: Reciprocal ST Depression. ST elevation in lead IIl is associated with reciprocal ST depression directly oppo- site lead III. Because lead aVL is the closest lead opposite lead Ill, aVL will show the most pronounced reciprocal ST depression among the standard electrocardiogram (ECG) leads. The standard limb lead ECG is shown in Figure 23.12.ooo eeeeee a i Spey eed uence sturseere pea in in in “peg oe ae {co Figure 23.12: Reciprocal ST Depression. ST elevation is present in leads II, Ill, and aVF and is most marked in lead Ill (arrows). Reciprocal ST depression is most pronounced in aVL (double arrows) because aVL is almost directly opposite lead Ill (see Fig. 23.11).Inferior LV wall = RCA 3: Short Axis, LV Apex 2: Short Axis, LV Papillary Muscle ———— Figure 23.13: Myocardial Distribu- tion of the Coronary Arteries, The igrams summarize the myocardial dis- tribution of the three coronary arteries, The diagram in the upper left represents the frontal view of the heart. The left is transected by three lines and 3. Line 1 is at the level of base of the left ventricle. The short axis view is shown on the upper right diagram. Line 2 corresponds to the mid- shownat the lower left.Line 3 corresponds to the apex of the left ventricle and the short axis is shown at the lower right. Ao, Aorta; Uy left vent monary artery; PDA, posterior descend- ing artery; PM, papillary muscle; RA, right atrium;| \ht coronary artery;V, to Verthe precordial electrodes superimposed on the heart.Figure 23.14: Diagrammatic Representation of the LAD and its Branches. The left main coronary artery divides into two main branches: the LAD and LCx coronary arteries. The LAD courses through the anterior interventricular groove. It gives diagonal branches laterally and septal branches directly perpendicular to the interventricular septum. LA, left atrium; LAD, left anterior descending artery; LCx, left circumflex; LY, left ventricle; RA, right atrium; RV, right ventricle. LAD First Septal Branch Septal Branches Anterior Surface Left Main Coronary Artery LCx Coronary Artery First Diagonal Branch Diagonal BranchesFigure 23.15: Extensive Anterior Myocardial Infarction (Ml). ST elevation is present in leads V,-,l,and aVL. Cardiac catheterization showed complete occlusion of the proximal left anterior descending (LAD) artery. Note that the ST elevation in | and aVLis due to involvement of the first diagonal branch, which is usually the first branch of the LAD. ST depression and aVF is a reciprocal change due to ST elevation in | and aVL.Pn or op ey ¥- {4g at av v2 Figure 23.16: Extensive Anterior Myocardial Infarction. ST elevation is present in V;-e,and aVL. Coronary angiography showed complete occlusion of the proximal LAD. This electrocardiogram is similar to that in Figure 23.15.Figure 23.17: Left Anterior Descending (LAD) Artery Oc- clusion Distal to the First Di- agonal Branch. The electrocar- diogram shows acute anteroseptal myocardial infarction with ST seg- ment elevation confined to V, to V4. This is due to occlusion of the LAD distal to the first diagonal branch (no ST elevatior land aVL) but proximal to the first sep- tal branch (ST elevation is present inv).oe Be ‘an aan rt rie Beet ee cee Baa ttt Figure 23.18: Acute High Lateral Myocardial Infarction from Isolated Lesion Involving the First Diagonal Branch of the Left Anterior Descending (LAD) Artery. ST segment elevation is confined to leads | and aVL. Coronary angiography showed complete occlusion of the first diagonal branch of the LAD. The LAD itself is patent. Occlusion of the first diagonal branch of the LAD causes ST elevation in | and aVL with reciprocal ST depression in Ill and aVF.Figure 23.19: Anterior and Inferior Myocardial Infarction. QS complexes with ST ele- vation is noted in V, to V; (anterior wall) and also in leads II, III, and aVF (inferior wall) due to an occluded left anterior descending artery that wraps around the apex of the left ventricle extending to the inferoapical left ventricular wall. The right coronary artery is small but patent.Acute Posterolateral Myocardial Infarction (MI). There is marked gments in V, to V3 with tall R waves in V;_2. The amplitude of theR d the ST segments are elevated. This represents an acute pos- circumflex coronary artery. The ST depression and tall R Figure 23.23: depression of the ST se waves in Vs_¢ is diminished an: terolateral MI from an occluded left waves in V,-V3 are reciprocal changes due to the posterior MI. Anterior subendocardial injury and straight posterior MI can be differentiated by recording Vy-9, which will show ST i important because ST elevation MI in- elevation if posterior Ml is present. This volving the posterior wall of the left ventricle may require wall subendocardial injury does not. thrombolysis, whereas anteriorFigure 23.25: Acute Posterolateral Myocardial Infarction (MI). ST depression is present in V,-V,. These changes can represent subendocardial injury involving the anterior wall or ST elevation MI involving the posterior wall of the left ventricle. The presence of ST elevation in V,,,and aVL favors acute posterolateral MI rather than anterior wall injury. This can be confirmed by recording V7_5, which will show ST elevation if posterior Ml is Present.A: Standard 12 lead ECG a as ——— Figure 23.26: Posterolateral Myocardial Infarction (MI) and Special Leads V, ». Electrocardio- gram (ECG) Ais a 12-lead ECG of a 58- year-old male presenting with chest pain. There is ST elevation in leads |, Vs,and Ve and ST depression in Vs. (B) The same as ECG A and shows only the precordial leads together with V; toV,,ST elevation is present inV,as well asV;,Ve,and V5 consistent with acute posterolateral MI. These examples show the impor- tance of recording special leads V; to Vs in confirming the diagnosis of pos- terolateral MI.ECG courtesy of Kittane Vishnupriya, MD.yocardial Infarction (MI) from Occlusion of the Note that the ST elevation in lead Il is more prominent nt is isoelectric in aVLand minimally elevated in lead |. h ST elevation in Ve from posterolateral Mi. Figure 23.27: Acute Inferior M Left Circumflex Coronary Artery. than lead Ill. Additionally, the ST segme ST depression is present in V, to V3 witFigure 23.28: Acute Myocardial Infarction with Normal Electrocardiogram (ECG). The ECG is from a 56-year-old male who presented with acute persistent chest pains. Serial ECGs were all normal although the cardiac markers were elevated, The coronary angiogram showed completely occluded left circumplex corona artery (LCx). Among the three coronary arteries, LCx coronary disease is the most difficult to diagnose electrocardiographically.Figure 23.30: Acute Inferior Myocardial Infarction (Ml). ST segment elevation is present i and aVF with reciprocal ST depression in | and aVL consistent with acute inferior MI. This is due to occlusion of the right coronary artery.Figure 23.31: Acute Inferolateral Myocardial Infarc- N. The ST segments are elevated and aVF with reciprocal inaVL.ST segments are elevated in V; and V¢ with ST seg- ment depression in V, and V,.Coro- nary angiography showed complete occlusion of the proximal right coro- nary artery. Scanned with CamScannerFigure 23.32: Acute Inferolat- eral Myocardial Infarction. ST elevation is noted in II, III, aVF,and V, to V, with reciprocal ST depre: in land aVL.The findings are similar to those in Figure 23.31.RCA Anterior “SG - -@- Posterior RCA Lateral wall lateral PM B: Short Axis (Level of PM) C: Short Axis (Level of Apex) Figure 23.39: (A) Myocardial Distribution of the Right Coronary Artery (RCA). The red stippled areas represent myocardial distribution of the RCA. These include the right: ventricular free wall, lower one-third of the posterolateral wall (A,B), inferior half of the ven- tricular septum (B) and the posterior portion of the LV apex (C).Note that the posteromedial PM (B) is supplied only by the RCA, whereas the anterolateral PM is supplied by two arteries, the LAD and LCx. Ao, aorta; LA, left atrium; LAD, left anterior descending; LCx, left circumflex; LV, left ventricle; PM, papillary muscle; RV, right ventricle. (D) Electrocardiogram (ECG) of RCA Involvement. Twelve-lead ECG showing a proximally occluded RCA. There is inferior my- ocardial infarction (MI) with ST elevation in lead Il! taller than lead Il and ST depression in aVL more pronounced than lead I, Even when right sided precordial leads are not recorded, the presence of right ventricular MI can be diagnosed by the ST elevation inV;.