An Anterior STEMI Equivalent —Reply

In Reply We thank Drs Rubin and Montana for their comments on our Challenges in Clinical Electrocardiography. They assert that the ST-segment depression in V2 is unlikely to be a reciprocal change to inferior wall ST-segment elevation, and more likely to represent an evolving de Winter pattern of hyperacute T waves in acute anterior myocardial infarction. While we somewhat agree with the authors, in the original description of de Winter pattern the ST-segment showed a 1- to 3-mm upsloping ST-segment depression at the J point in all precordial leads V1 to V6 with tall positive and symmetrical T waves. The electrocardiogram in question showed ST-segment elevation in lead V1 and hyperacute T waves in V2 to V6 with ST-segment depression in V2. Isolated ST-segment depression in V2 is not common with the de Winter pattern. We hypothesized that this isolated ST-segment depression in V2 could be owing to sparing of the diagonal artery. In high lateral infarcts related to the diagonal artery, the ST-segment vector points toward the axilla and is usually directed from 0 ° to −90° in the frontal plane, which is represented by leads I and aVL. As lead V2 is to the left and higher than the center of the heart, the frontal plane projection of lead V2 also points toward the axilla. Therefore, the structure of the complexes in V2 frequently resemble the form in lead aVL. Thus, lead V2 also may show reciprocal changes in cases with ST-segment elevation in inferior leads. In the presence o...
Source: JAMA Internal Medicine - Category: Internal Medicine Source Type: research