ST-segment elevation in precordial leads

Figure 4.16 Acute myocardial infarction in a patient with rapid atrial fibrillation. The ECG shows ST-segment elevation in V2-V5, I and VL. Leads II, III, and VF present an evident ST-segment depression as a mirror pattern of ST-segment elevation in precordial leads. This is a pattern of acute coronary syndrome with ST-segment elevation of the anterior wall according to the classical classification.

Also, the ST-segment elevation is seen in the precordial and inferior leads in the presence of an STE-ACS due to the very proximal occlusion of the RCA before the RV marginal branches. In this case usually the ST-segment elevation in VI > V3-V4, while in an STE-ACS due to the distal occlusion of the LAD, the contrary occurs (i.e. the ST-segment elevation is VI < V3). Table 4.2 shows the ECG criteria that allow differentiating the culprit artery (proximal RCA or distal LAD) in the case of ST-segment elevation in precordial leads and inferior leads. 

Table 4.2 The ST segment elevation in precordial leads (especially V1- V3-V4) and inferior leads (II, III and VF).

Figure 4.43 The algorithm to locate the zone of LAD occlusion in case of ACS with predominant ST-segment elevation in precordial leads. In the lower right side is presented an example to calculate the formula sum of...

It has been shown that in an STE-ACS due to distal to D1 and SI, occlusion of long LAD generates the ST-segment elevation in precordial leads and in II, III and VF. However, this morphology may also be explained by an occlusion in LAD in presence of a total RCA occlusion with collateral vessels from the LAD to the RCA, even in the absence of a considerably long LAD. There is not any ECG criterion that may help us to differentiate these two cases, because in both situations the ST-segment elevation in precordial leads is more important than in inferior leads. 

Figure 4.36 (A) Typical ECG in case of STE-ACS due to occlusion of very dominant RCA distal to RV branches. Observe the ST-segment elevation in inferior leads (III > II) and ST-segment depression the ST-segment depression in V1-V3 (occlusion distal to the take-off of RV branches). Furthermore, the ST-segment elevation in V6 is greater than 2 mm (occlusion of very dominant RCA). In extreme right precordial leads the ST is isoelectric in V3R and...

Figure 4.49 (A) A 39-year-old patient with long-standing precordial pain without ischaemic characteristics. There is an ST-segment elevation in many leads and in someone with final negative T wave but without Q waves and with PR elevation in VR with depression in II. The clinical history,...

Fujiki A, Usui M, Nagasawa H, Mizumaki K, Hayashi H, Inoue H. ST segment elevation in the right precordial leads induced with class IC antiarrhythmic drugs insight into the mechanism of Brugada syndrome. J Cardiovasc Electrophysiol 1999 10(2) 214-18. 

The VR lead is usually not taken into account by the cardiologist when interpreting an ECG. Nonetheless, ST-segment elevation in VR is very important in the presence of an STE-ACS in the precordial leads because it suggests that LAD occlusion is proximal to SI (Figures 4.18 and 4.19). 

Figure 4.3 Observe how an amplified ECG (4x) allows the proper assessment of ST-segment deviation. (A) Post-myocardial-infarction patient with slight ST-segment elevation in right precordial leads. When amplified ECG...

Incomplete occlusion of LAD involving diagonal but not septal branches or selective occlusion of Dl Often ST-segment elevation in I, VL and V5-V6 and sometimes even in more precordial leads, and ST-segment depression in II, III and VF (III > II). 

The presence of ST-segment elevation in the right precordial leads (V1-V3) and ST-segment depression in the left-sided leads (aVL, I and V4—... 

When in a patient with STE-ACS in precordial leads there are some criteria that do not fit well with the presumed place of occlusion, the presence of ischaemia due to critical multivessel disease may be suspected (see Figure 4.44). It looks like a LAD occlusion proximal to D1 but was not clear if the occlusion was also proximal to SI (ST-segment elevation in VR and ST-segment depression in VI). The case corresponds to a critical... 

Figure 8.20 (A) ECG shows ST-segment depression especially in precordial leads (V3-V6) with positive T wave very evident in leads V3-V5 (regional subendocardial involvement). There is no ST-segment elevation in VR.

Recurrent ST-segment elevation, especially with pain, detected with continuous multilead ST-segment monitoring (Akkerhuis et al., 2001). -According to the ST-segment elevation in the precordial or inferior leads and the presence of mirror patterns, the ECG allows for location of the coronary... 

Right-sided precordial leads were obtained in 18 patients. In each of the 12 with 0.5 mm ST-segment elevation in V4R, the RGA contained the culprit lesion. In two of the four patients with < 0.5 mm ST-segment elevation or an isoelectric ST-segment in V R, the culprit lesion was in the RGA, and in two patients it was in the LGX. Each of the two patients with ST-segment depression in V4R had the culprit lesion in the LGX. 

This 12-lead electrocardiogram shows typical characteristics (Vj, Vj, V4) of an anterior-wall myocardial infarction (Ml). Note that the R waves don t progress through the precordial leads. Also note the ST-segment elevation in leads Vj and Vj. As expected, the reciprocal leads II, III, and aVp show slight ST-segment depression. 

Figures 3.18 and 3.19 show the evolution of two Mis from the acute phase with a huge ST-segment elevation until the appearance of Q wave of necrosis and negative T wave of subepicardial ischaemia. In Figure 3.20, a patient with chronic MI of inferior wall presents in the same ECG a different grade of ECG pattern of subepicardial ischaemia (negative and deep T wave in inferior leads, tall and positive T wave in right precordial leads as a mirror pattern and flat T wave in V6).

---