STEMI ECG

• The precordial leads can be classified as follows:

• Septal = V1-2
• Anterior = V2-5
• Anteroseptal = V1-4
• Anterolateral = V3-6, I + aVL
• Extensive anterior / anterolateral = V1-6, I + aVL

Where to expect reciprocal changes?

PAILS (8)

Posterior MI – anterior reciprocal changes

Anterior MI – inferior reciprocal changes
Inferior MI – lateral reciprocal changes

Lateral MI <-> inferior or septal reciprocal changes*** exception to mnemonic

Septal MI – posterior reciprocal change
Extensive anterolateral MI
• ST elevation in V2-6, I and aVL.
• Reciprocal ST depression in III and AVF.
Extensive anterior MI (“tombstoning” pattern)

• Massive ST elevation with “tombstone” morphology is present

throughout the precordial (V1-6) and high lateral leads (I, aVL)
• This pattern is seen in proximal LAD occlusion and indicates a large
territory infarction with a poor LV ejection fraction and high
likelihood of cardiogenic shock and death
Anterior-inferior STEMI
• ST elevation is present throughout the precordial and inferior leads
• There are hyperacute T waves, most prominent in V1-3
• Q waves are forming in V1-3, as well as leads III and aVF
• This pattern is suggestive of occlusion occurring in “type III” or
“wraparound” LAD (i.e. one that wraps around the cardiac apex to
supply the inferior wall)
Anterior MI
• St elevation at V2-V4
• Reciprocal st depression at inferior lead
 Isolated posterior mi
• St depression at anterior & septal lead ( V2-v4)
• Tall broad R wave
• Upright T wave
• The posterior wall supplied by either the circumflex artery or the RCA. Occclusion of
either artery may affect the posterior wall, regardless of "dominance" (which refers to
the arterial supply of the inferior wall.) Common branches affected are the obtuse
marginal branches and posterolateral branch of the circumflex artery, and posterior
branches of the RCA.
• Circumflex occlusion (or occlusion of one of its obtuse marginal branches) accounts
for the majority of “isolated” posterior AMI.
• RCA occlusion is the most common cause of “concurrent posterior and inferior”
AMI, because the RCA is usually dominant and branches frequently supply the
posterior wall
Inferoposterior MI
• ST depression at V1-V3
• St elevation at II, III , aVF
• Reciprocal changes at lateral leads aVL
Repeated ecg with right sided leads
Inferior Mi with right ventricular
involvement
• St elevation at V1
• St depression at V2
• Isoelectric ST at V1 with ST depression at V2
• St elevation at III > II
Inferior Mi with right ventricular infarction
• There is an inferior STEMI with ST elevation in lead III > lead II
• V1 is isoelectric while V2 is significantly depressed
• There is ST elevation throughout the right-sided leads V3R-V6R
Repeated ecg with posterior leads
inferior-lateral-posterior STEMI
• Horizontal ST depression in V1-3
• Tall, broad R waves (> 30ms) in V2-3
• Upright T waves in V2-3
• Marked ST elevation in V7-9 with Q-wave formation confirms
involvement of the posterior wall
• Posterior MI is suggested by the following changes in V1-3:
• Horizontal ST depression
• Tall, broad R waves (>30ms)
• Upright T waves

Explanation of the ECG changes :

• ST elevation becomes ST depression
• Q waves become R waves
• Terminal T-wave inversion becomes an upright T wave
High lateral MI