Chest pain with anterior ST depression: look what happens if you use posterior leads.

Don ' t forget to watch theWebinar: Smith and Pendell Meyers interpret ECGs for OMI or not OMI on Monday Feb 12 at 11 AM U.S. Central time.  Register here:https://zoom.us/webinar/register/7617067094184/WN_LMN0vPb1Rz-HZu12K-QuYQWritten by Jesse McLarenA 65 year old with a history of atrial flutter, CABG and end-stage renal disease on dialysis presented with 3 days of fluctuating chest pain, which was ongoing at triage. What do you think? Do you need posterior leads?There ’s atrial flutter with controlled ventricular response, a non-specific intra-ventricular conduction delay, borderline right axis, normal R wave progression and normal voltages. The abnormal depolarization from the IVCD can produce secondary repolarization abnormalities, but here there appears to b e superimposed primary ST depression V2-4 indicating posterior OMI. Here ' s the prior ECG:This confirms thew anterior ST depression is new.The first ECG was labeled “anterior subendocardial ischemia”, but subendocardial ischemia does not localize. If there were diffuse ischemic STD, with precordial STDmaxV5-6 and reciprocal STE-aVR, this would be non-specific subendocardial ischemia from ACS or supply-demand mismatch.But here there is ischemic STDmaxV1-4, which is not “anterior subendocardial ischemia” but rather reciprocal to posterior OMI. So a patient with high pretest probability (prior CABG with new chest pain), had new ECG changes showing posterior OMI. Do you need posterior leads...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs