EKG September

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**Follow up by Dr Smer**

Great job guys, you all got it right. Faysal, you dissected this EKG very well…!  I’d add that the ST-depression in V1-3 could be related to subendocardial ischemia, either due to critical coronary stenosis or demand ischemia. In both conditions you still have blood flow to that myocardial/coronary territory where you see ST depression. However, having Positive T wave in the setting of ST-depression in V1-3 should make you think of Posterior STEMI, NO BLOOD FLOW, totally occluded artery.  
The Mirror sign is what Faysal mentioned by flipping the EKG, so the r wave becomes q wave, ST depression becomes elevation and positive T wave becomes inverted. Simple, yet helpful to identify posterior MI. You still need to obtain posterior EKG V7-9 to see ST elevation. This patient did have ST elevation in the posterior lead and he went to cath lab, which showed totally occluded left circumflex artery treated with drug eluting stent. 

5 Responses

  1. Faysal Alghoula

    Sinus rhythm, normal axis, ST depression in the leads V1,2&3, which is very concerning for posterior MI, If you flip the EKG then it is as if recorded from the opposite (posterior) aspect of the heart it’ll look like ST elevation.
    Will do another EKG with posterior leads and will follow the Trops.

  2. Rahma

    Just a follow up on my earlier comment:
    Posterior MI is suggested by horizontal ST depression and upright T wave (seen in this case) and also by dominant R in V2 (not seen here, possibly as the ECG was taken earlier in the course of infarct).
    The other thing I believe is that with strong clinical suspicion and posterior MI on ECG. It’s type 1 and door to cath lab should be 90 minutes even with a negative initial Troponin.


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