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Posterior myocardial infarction with isolated ST elevations in V8 and V9: Is this an “ST elevation MI”?

Published online by Cambridge University Press:  21 May 2015

Lance Brown ,
Jessica Sims  and
Alessandra Conforto
Lance Brown*
Affiliation:
Emergency Department, Loma Linda University Medical Center, Loma Linda, Calif. Emergency Department, Los Angeles County Medical Center/Keck School of Medicine of the University of Southern California, Los Angeles, Calif.
Jessica Sims
Affiliation:
Emergency Department, Los Angeles County Medical Center/Keck School of Medicine of the University of Southern California, Los Angeles, Calif.
Alessandra Conforto
Affiliation:
Emergency Department, Los Angeles County Medical Center/Keck School of Medicine of the University of Southern California, Los Angeles, Calif.
*
Department of Emergency Medicine A-108, Loma Linda University Medical Center, 11234 Anderson St., Loma Linda CA 92354 USA; 909 558-4344, fax 909 558-0121, [email protected]

Abstract

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We report a case of a 53-year-old man whose first manifestation of coronary artery disease was an acute isolated posterior myocardial infarction (IPMI). Acute IPMI is relatively uncommon and predominantly due to occlusion of the left circumflex coronary artery. IPMI is challenging to diagnose due to the absence of ST segment elevation on a standard 12-lead electrocardiogram (ECG) even in the setting of total coronary artery occlusion and transmural (Q-wave) infarct. We discuss the diagnostic implications of the absence of tall R waves in leads V1 and V2 on this patient’s ECG. The utility of posterior leads (V7 through V9) is demonstrated. The controversy surrounding the use of thrombolytic therapy or primary angioplasty in the setting of acute IPMI without ST segment elevation on a standard 12-lead ECG is reviewed.

Keywords

posterior myocardial infarctionposterior ECG leadsemergency department
Type
Case Report • Observations De Cas
Information
Canadian Journal of Emergency Medicine , Volume 5 , Issue 2 , March 2003 , pp. 115 - 118
Copyright
Copyright © Canadian Association of Emergency Physicians 2003

References

1.Brady, WJ.Acute posterior wall myocardial infarction: electrocardiographic manifestations. Am J Emerg Med 1998;16:409–13.CrossRefGoogle ScholarPubMed
2.Brady, WJ., Erling, B., Pollack, M., Chan, TC.Electrocardiographic manifestations: acute posterior wall myocardial infarction. J Emerg Med 2001;20:391–401.Google Scholar
3.Agarwal, JB., Khaw, K., Aurignac, F., LoCurto, A.Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram. Am J Cardiol 1999;83:323–6.Google Scholar
4.Matetzky, S., Freimark, D., Feinberg, MS., Novikov, I., Rath, S., Rabinowitz, B., et al. Acute myocardial infarction with isolated ST-segment elevation in posterior chest leads V7–9: “Hidden” ST-segment elevations revealing acute posterior infarction. J Am Coll Cardiol 1999;34:748–53.CrossRefGoogle ScholarPubMed
5.O’Keefe, JH., Sayed-Taha, K., Gibson, W., Christian, TF., Bateman, TM., Gibbons, RJ.Do patients with left circumflex coronary artery-related acute myocardial infarction without ST-segment elevation benefit from reperfusion therapy? Am J Cardiol 1995;75:718–20.CrossRefGoogle ScholarPubMed
6.Zalenski, RJ., Cooke, D., Rydman, R., Sloan, EP., Murphy, DG.Assessing the diagnostic value of an ECG containing leads V4R, V8, and V9: the 15-lead ECG. Ann Emerg Med 1993;22:786–93.CrossRefGoogle ScholarPubMed
7.Oraii, S., Maleki, M., Tavakolian, AA., Eftekharzadeh, M., Kamangar, F., Mirhaji, P.Prevalence and outcome of ST-segment elevation in posterior electrocardiographic leads during acute myocardial infarction. J Electrocardiol 1999;32:275–8.CrossRefGoogle ScholarPubMed
8.Khaw, K., Moyeyra, AE., Tannenbaum, AK., Hosler, MN., Brewer, TJ., Agarwal, JB.Improved detection of posterior myocardial wall ischemia with the 15-lead electrocardiogram. Am Heart J 1999;138:934–40.Google Scholar
9.Brady, WJ., Hwang, V., Sullivan, R., Chang, N., Beagle, C., Carter, CT., et al. A comparison of 12- and 15-lead ECGs in ED chest pain patients. Impact on diagnosis, therapy, and disposition. Am J Emerg Med 2000;18:239–43.Google Scholar
10.Rich, MW., Imburgia, M., King, TR., Fischer, KC., Kovach, KL.Electrocardiographic diagnosis of remote posterior wall myocardial infarction using unipolar posterior lead V9. Chest 1989;96:489–93.CrossRefGoogle ScholarPubMed
11.Wung, SF., Lux, RL., Drew, BJ.Thoracic location of the lead with maximal ST-segment deviation during posterior and right ventricular ischemia: comparison of 18-lead ECG with 192 estimated body surface leads. J Electrocardiol 2000;33:167–74.Google Scholar
12.Menown, IBA., Allen, J., Anderson, JM, Adgey, AA.ST depression only on the initial 12-lead ECG: early diagnosis of acute myocardial infarction. Eur Heart J 2001;22:218–27.Google Scholar
13.Boden, WE., Kleiger, RE., Gibson, RS., Schwartz, DJ., Schechtman, KB., Capone, RJ., et al. Electrocardiographic evolution of posterior acute myocardial infarction: importance of early precordial ST-segment depression. Am J Cardiol 1987;59:782–7.CrossRefGoogle ScholarPubMed
14.Perloff, JK.The recognition of strictly posterior myocardial infarction by conventional scalar electrocardiography. Circulation 1964;30:706–18.Google Scholar
15.Seyal, MS., Swiryn, S.True posterior myocardial infarction. Arch Intern Med 1983;143:983–5.CrossRefGoogle ScholarPubMed
16.Cannon, CP., Battler, A., Brindis, RG., Cox, JL., Ellis, SG., Every, NR., et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndrome Writing Committee). J Am Coll Cardiol 2001;38:2114–30.CrossRefGoogle Scholar
17.Mattu, A., Brady, WJ., Perron, AD., Robinson, DA.Prominent R wave in lead V1: electrocardiographic differential diagnosis. Am J Emerg Med 2001;19:504–13.Google Scholar
18.Melendez, LJ, Jones, DT., Salcedo, JR.Usefulness of three additional electrocardiographic chest leads (V7, V8 and V9) in the diagnosis of acute myocardial infarction. CMAJ 1978;119:745–8.Google Scholar
19.Wung, SF., Drew, BJ.New electrocardiographic criteria for posterior wall acute myocardial ischemia validated by a percutaneous transluminal coronary angioplasty model of acute myocardial infarction. Am J Cardiol 2001;87:970–4.Google Scholar
20.Gupta, M, Tabas, JA., Kohn, MA.Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med 2002;40:180–6.Google Scholar
21.Gibler, WB., Armstrong, PW., Ohman, EM., Weaver, WD., Stebbins, AL., Gore, JM., et al. Persistence of delays in presentation and treatment for patients with acute myocardial infarction: The GUSTO-I and GUSTO-III experience. Ann Emerg Med 2002;39:123–30.CrossRefGoogle ScholarPubMed
22.Novak, PG., Davies, C., Gin, KG.Survey of British Columbia cardiologists’ and emergency physicians’ practice of using nonstandard ECG leads (V4R to V6R and V7 to V9) in the diagnosis and treatment of acute myocardial infarction. Can J Cardiol 1999;15:967–72.Google Scholar
23.Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;1:397–401.Google Scholar
24.Second International Study of Infarct Survival (ISIS-2) Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988;2:349–60.Google Scholar
25.Braunwald, E., Cannon, CP.Non-Q wave and ST segment depression myocardial infarction: Is there a role for thrombolytic therapy? [editorial]. J Am Coll Cardiol 1996;27:1333–4.Google Scholar
26.Langer, A., Goodman, SG., Topol, EJ., Charlesworth, A., Skene, AM., Wilcox, RG., et al. Late assessment of thrombolytic efficacy (LATE) study: prognosis in patients with non-Q wave myocardial infarction. J Am Coll Cardiol 1996;27:1327–32.CrossRefGoogle ScholarPubMed
27.Shah, A., Wagner, SG., Green, CL., Crater, SW., Sawchak, ST., Wil-dermann, NM., et al. Electrocardiographic differentiation of the ST-segment depression of acute myocardial injury due to the left circumflex artery occlusion from that of myocardial ischemia of nonocclusive etiologies. Am J Cardiol 1997;80:512–3.Google Scholar
28.Midgette, AS., O’Connor, GT., Baron, JA., Bell, J.Effect of intravenous streptokinase on early mortality in patients with suspected acute myocardial infarction. Ann Intern Med 1990; 113:961–8.Google Scholar