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Tuesday, May 13, 2014

New thoughts on posterior MI for EMS

Many savvy medics will check the "extra" ECG leads V7 - V9 to look for a posterior MI. However, this isn't always necessary, since the appearance of leads V1 - V3 will often show sufficient evidence of an acute MI. The only two problems here are
  1. Many medics don't know the classic criteria for posterior AMI.
  2. The classic criteria may need to be changed somewhat!
I wrote an article about this topic a few years ago in a post at EMS 12-Lead.  A newly published case report got me thinking about this again, though! 

(Feel free to check out that link for a longer discussion.)

The Case Report
In the article "Acute Coronary Ischemia Identified by EMS Providers in a Standing Middle-aged Male with Atypical Symptoms," the authors describe the case of apatient who had syncope, followed by cardiac arrest. After the patient had ROSC, they obtained an ECG:

SOURCE
They described this pattern of anterior ST depression only as "anterolateral ischemia," but could this really be a posterior STEMI?

ECG findings - The old thinking
For years, the standard teaching on identifying a posterior MI has emphasized some common elements. Brady summarized the most important of these:
  • Horizontal ST depression in V1-V4
  • Tall, broad R waves (>30ms)
  • Upright T waves
  • Dominant R wave (R/S ratio > 1) in V2
So, a classic posterior MI should look something like:

Problems with the old thinking?
The short-cut way to diagnose a posterior MI involves "flipping" the ECG. The idea is that the ST depression in the anterior leads is a "mirror" view of ST elevation in the posterior wall, and that the tall R-waves are actually deep Q-waves.

For example,  when we take the ECG above, and "flip" leads V1 - V3, it now looks like a standard STEMI.

LEFT: Unflipped - just boring ST depression
RIGHT: Flipping reveals an exciting STEMI. It's Magic!

So, our "classic" posterior, when it is flipped, looks like a STEMI. 

There is one problem though. The flipped ECG shows a big Q-wave, and the T-wave has started to invert. Usually, these findings aren't found in the early , acute stages of a STEMI.

Evolution of ECG in STEMI (source)
Instead, this pattern of Q-waves and T-wave inversion suggests an AMI that has been progressing for a few hours.

ECG findings - The new thinking
This problem - that a classic posterior STEMI looks like a subacute or old MI - was described by the authors of Common pitfalls in the interpretation of electrocardiograms from patients with acute coronary syndromes with narrow QRS: a consensus report. These 13 cardiologists agreed that the old definition of posterior MI, that relies on tall R-waves and upright T-waves in leads V1 - V4, describes
"... the late “mirror image” of fully evolved ST-segment MI (STEMI) (Q waves with terminal T-wave inversion) and not the acute phase of STEMI."
They do not propose a better definition of a posterior STEMI ECG pattern. They do, however, offer this example of an ECG that better illustrates a truly acute posterior STEMI, resulting from a left circumflex occlusion. Note the ST depression in V1 - V3, and no significant R-waves or T-waves.



Back to the case report!
The ECG from the case at the start of this post showed ST depression in V1 - V4, but only small R-waves, and only a hint of an upright T-wave:


This ECG does not fulfill the "Brady" criteria listed above, but if we "flip" the ECG, we see that...

LEFT: Zoom on V1-V3
RIGHT: Flipped!
... we indeed have a classic, acute-looking STEMI! And in line with this interpretation, the patient was found to have a complete occlusion of the circumflex.

The Bottom Line
We don't have a good "new" definition of posterior STEMI that is based on interpretation of the anterior leads, but it appears that the "old" definition has shortcomings. Hopefully, future research will clarify the best ways to discern a posterior MI on the standard 12-lead ECG.





37 comments:

  1. Given the normal V6 and no ST-E in aVR in the initial ECG, I find it hard to believe that ECG shows "antero-lateral ischemia". Actually, I always find it hard to believe when someone purports to localize ischemia (I was once on that fool's errand).

    ReplyDelete
    Replies
    1. Right! Common, and persistent, misunderstanding.

      By contrast, I recall from somewhere in Marriott's Practical Electrocardiography that you can use T wave inversion to localize ischemia, e.g. during stress tests. This subject, however, is not in my bailiwick!

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  2. Nice tracings and good concepts Brooks! That said - "plus ça change, plus c'est la même chose" (= the more things change - the more they remain the same). Tall anterior R waves were never intended to be a criterion for "acute" posterior MI. The biphasic T waves in your 2nd tracing (of "classic" post MI) - is not what I conceive of as classic "acute" posterior MI for precisely the reasons you state (the terminal positive portion of the T wave implies you are no longer in the "earliest stage" because this corresponds to the stage of T inversion while the ST segment starts coming down when flipped in a mirror). Instead - your last ECG (showing just V1,V2,V3 upright and then flipped) is a "classic" picture of acute posterior MI - with the "mirror test" being all that is needed for those not yet able to instantly recognize this pattern with leads upright. Posterior leads are NOT needed (in my opinion) when the picture looks like this. My impression is that this describes things as they have always been for as Iong as I've been interpreting.

    As to "localizing ischemia" - stress testing does NOT do this. First - the patient is upright during a treadmill test - which changes orientation to some extent. My impression is that we pick up subendocardial ischemia - with the BEST lead on simple ETT being lead V5. Victor Froelicher I believe was among the first to show that isolated inferior ST depression on ETT during exercise had very poor specificity for a positive test .... (but specificity goes way up if you develop both inferior AND lateral precordial ST depression). Anterior ST changes on ETT are far less often seen .... The "money" is in leads V4,V5,V6 ... with Bottom Line that ETT can't be used to localize ischemia. On the other hand - I remain under the deception that moderate-to-deep symmetric T inversion that is localized to a specific lead area on a resting 12-lead ECG does indeed correlate with area of ischemia.

    ReplyDelete
    Replies
    1. Ken, I very much appreciate your perspective here!

      Unfortunately, the requirement for tall R waves and biphasic/upright T waves is enshrined in many sources that EM and EMS use for ECG education.

      For example, Life in the Fast Lane, Academic Life in Emergency Medicine, and Amal Mattu all repeat the same definition as Brady does. My "classic posterior" ECG example was taken from a cardiology paper on STEMI-equivalents.

      So, where did the erroneous definition of acute posterior MI come from then? I suspect that the older literature, based in the antiquated language of "Q-wave MIs" is to blame.

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  26. Hello everyone here i want to share a marvelous testimony oh how Dr OKOLO HERBAL MIXTURE CREAM saved me from shame and disgrace .So Many Women Today Cheat On Their Husband All Because Of The Poor Performance Of Their Husband In Bed,I Have Come To Know That Women Love Men Who Last Long In Bed And Also Has That Big Dick That Can Make Them Scream And Also Make Them Rich Their Climax,Women Truly Love Good Sex. I Have Been Passing True Sexual Problems For The Past Six Years Now All Because Of The Size Of My Penis And My Poor Performance In Bed I Caught My girlfriend With another man I Was Heart Broken And Confused When I Asked Her Why She Did All What She Did She Told Me I Was Not Good In Bed That I Can Not Satisfy Her That She Needs A Man Who Can Satisfy Her That Was How She Broke Up With Me At That Moment. I Told My Self I Was Never Going To Have Any Thing To Do With Any Woman Again I Started Going To The Club Sleeping Around With Different Girls at a Point I Got Tired Of Living That Kind Of Life Because That Was Never Part Of Me I Was On Line Last Month When I Came Across so many testimonies On  Dr OKOLO How He Made their Sex Life Come Back To Life And That He Had Giving Them The Real Size Of Penis A Man  Suppose To Have I Got Interested And I Contacted Him At Once Luckily For Me He Was Online After About 30 Minutes He Replied Me And Then He Told Me Every Thing I Needed To Do After Every Thing He Sent Me A herbal cream Package True The DHL courier  Service Which I Received The Next three Days And Then I Started Using Them As Instructed By Him After About 2 Weeks I Started Seeing My Penis Got to 8 inches And i Felt So Many Changes Inside Of Me And Today I Am Happy today i can Last Up more than 1 Hour On Bed and can go up to 10 rounds with my girlfriend All Thanks To Dr OKOLO For Making Me Feel Like A Man Once Again. he can also do the following..PENIS ENLARGEMENT, BREAST ENLARGEMENT, DIABETES 1/2,HIV/AIDS,HERPES,CANCER,PREMATURE EJACULATION,WEAK ERECTION,ERECTILE DYSFUNCTION ,LOW SPERM COUNT PREGNANCY HERBAL MEDICINE HIGH BLOOD PRESSURE LOW SPERM COUNT LYME DISEASE many more..  Contact Via Email drokolosolutioncenter@gmail.com or  whatssapp--+2347031895935

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  27. Am Laura Mildred by name, i was diagnosed with Herpes 4 years ago i lived in pain with the knowledge that i wasn't going to ever be well again i contacted so many herbal doctors on this issue and wasted a large sum of money but my condition never got better i was determined to get my life back so one day i saw Mr. Morrison Hansen post on how Dr. Emu saved him from Herpes with herbal medicine i contacted Dr. Emu on his Email: Emutemple@gmail.com we spoke on the issue i told him all that i went through and he told me not to worry that everything will be fine again so he prepared the medicine and send it to me and told me how to use it, after 14 days of usage I went to see the doctor for test,then the result was negative, am the happiest woman on earth now thanks to Dr. Emu God bless you. Email him at: Emutemple@gmail.com Call or Whats-app him: +2347012841542 

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  28. Am Lucy Morgan from Atlanta Georgia  i was suffering from genital herpes, oral herpes, shingles. Before I came in contact with dr. Kham It is no longer news that the Acquired immune deficiency syndrome Herpes Virus is increasing by the day, The fear is that many people living with the sickness are scared of saying it because of the stigma that comes along with it.I am bold enough among many others to state that there is now a potent cure to this sickness but many are unaware of it.I discovered that I was infected with the virus 3 months ago, after a medical check-up. My doctor told me and I was shocked, confused and felt like my world had crumbled. I was dying slowly due to the announcement of my medical practitioner but he assured me that I could live a normal life if I took my medications, In a bid to look for a lasting solution to my predicament, I sought for solutions from the voodoo world. I went online and searched for every powerful trado-medical practitioner that I could severe, because I heard that the African Voodoo Priests had a cure for Herpes syndrome. It was after a little time searching the web that I came across one Dr. Kham website who offered to help me, He gave me some steps to follow and I meticulously carried out all his instructions. Two days ago to be precise, I went back to the hospital to conduct another test and to my amazement, the results showed that " I am NEGATIVE" You can free yourself of this Herpes virus by consulting this great African Voodoo Priest via this EMAIL dr.khamcaregiver@gmail.com or dr.khamcaregiver@outlook.com]  WHATSAPP NUMBER +2348159922297, You can Also Visit his website to know more about him at > https://drkhamherbalhealingcenter.wordpress.com/    

    HE CONFIDENTLY TOLD ME HE CAN ALSO SOLVE THE FOLLOWING PROBLEMS WITH ANY DELAY IN TIME

    PREGNANCY spell

    EPILEPSY cure spell

    GENPILENCI

    HIV AIDS.

    PREGNANCY

    DIABETICS

    STROKE.

    EXPANDS OF PENIS BREAST

    H.P.V TYPE 1 TYPE 2 TYPE 3 AND TYPE 4. TYPE 5.

    HUMAN PAPILLOMAVIRUS

    HERPES.

    SYPHILIS.

    CANCER.

    HEPATITIS A B and C.

    HIGH BLOOD PRESSURES AND BODY BOILS.

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  29. get your ex back with a love spell that works fast.
    Dr.Jumba has helped thousands of women get their Ex boyfriends back using his real effective love Spell. After my boyfriend of one year broke up with me, I could barely speak without crying. I felt blindsided and didn't know what to do. I didn't know if I could get him back and the anxiety was unbearable. I needed him back desperately because I loved him so much. So I contacted this great spell caster for help. He helped me cast a return love spell on him and just within 11 hours my boyfriend came back to me crying and begging for my forgiveness. Dr. Jumba released him to know how much I loved and wanted him. And He also opened his eyes to picture how much love we have shared together. As I am writing this testimony right now I am the happiest woman on earth. I want to recommend this great spell caster to anyone that truly needs an urgent solution to a love break up. Email him at wiccalovespelltools@yahoo.com or wiccalovespelltools@gmail.com or Call/WhatsApp him: +19085174108 "I'm so grateful and can say that if you have been broken up with and want to get that person back, Dr.Jumba is the best! I'll never forget how much he helped me
    WEBSITE : drjumbaspellhome.wordpress.com , blog : https://wiccaspelltools.blogspot.com/

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  30. Greatest thanks to Dr ODOGWU,   for his herbal drugs that he prepared for me and when i start using it in just 2weeks i was completely cured and that ended my HERPES SIMPLEX 1&2 DISEASE i am so happy and grateful to Dr ODOGWU  . after reading about him on a testimony of Jason Cash on a blogger. i knew suddenly Dr ODOGWU  was the right Doctor to cure my HERPES SIMPLEX 1&2 DISEASE. i discuss with Dr  ODOGWU  and he prepared a herbal medicine for me and when it got sent to me in south korean . i used the herbal medicine and 2weeks and i went to check up again. after 15years of suffering from HERPES SIMPLEX 1&2 at last i am smiling once again. Dr ODOGWU  also has remedy to others disease like COLD SORES,HIV/AIDS,DIABETES.CANCER,HIGH BLOOD PRESSURE AND MANY MORE. I oblige everyone to contact this powerful herbalist Dr ODOGWU  and be free from your suffering. contact his WhatsApp line: +2348118705388    or his Email: dr.odogwucaregiver@gmail.com     

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  31. My name is James Isabella,I am from the USA . It's a pleasure for me to write this testimony about how I got my Genital Herpes cured a month ago. I have been reading so many comments of some people who were cured from various diseases by Dr Biya, but I never believed them. I was hurt and depressed so I was too curious and wanted to try Dr Biya, then i contacted him through his email when i contacted him, he assured me 100% that he will help me, i pleaded with him to help me out. My treatment was a great success, he healed me just as he promised. He sent me his medication and asked me to go for check up after 3 weeks of taking the medication. i agreed with him i took this medication and went for check up after a month later , to my greatest surprise my result was negative after the treatment, i am really happy that i am cured and healthy again. I have waited for 3weeks to be very sure I was completely healed before writing this testimony. I did another blood test one week ago and it was still Herpes negative. So I guess it's time I recommend anyone going through Herpes contact him through What's app +2348111856507 or Gmail: drbiyajatto@gmail.com God bless you Dr Biya. Dr Biya also has remedy to others disease like COLD SORES,HIV/AIDS,DIABETES.CANCER,HIGH BLOOD PRESSURE AND MANY MORE. https://drbiyajatto.wixsite.com/drbiyajattoherbalhom https://m.youtube.com/results?search_query=dr+biya+herbal+medication

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  32. I am very happy today to share this amazing testimony on how Dr. AFRID the herbal doctor was able to cure me from my Herpes Virus with his herbal medicine. I have been a herpes patient for almost 8 months now and have tried different methods of treatment to ensure that I am cured of this terrible disease, but none worked for me, so I had to leave everything to God to handle as I was a Christian who had faith that one day God would intervene in my life, yet I felt so sad and desperate as I was losing almost everaything due to my illness, A few months ago while I was surfing the internet I saw different recommendation about Dr AFRID on how he have been using his herbal Medicine to treat and cure people, these people advice we contact Dr. AFRID for any problem that would help immediately, I contacted Dr AFRID and I told him how I got his contact and also about my disease, after some time Dr. AFRID told me to have faith that he would prepare for me a medication of herbal herbs, he told me I would take this medicine for a few weeks and also asked my home for home address so as possible for him to submit the drug for me, so my good friends after all the process and everything Dr AFRID actually sent me the medicine, I took it as I was directed by Dr. AFRID, after a few weeks passed, while on Dr. AFRID medication I began to experience changes in my body, I had to call my doctor at the hospital for some blood test, after test my hospital doctor told me that I was no longer with the herpes virus and my blood is pretty good, I can not even believe this, Friends well today i am Herpes Free and i want everyone to know that there is a cure for herpes for those who will contact Dr AFRID after reading my testimony, you can kindly contact Dr. AFRID in (DRAFRIDHERBALHOME@GMAIL.C OM) or whatsApp him +2349057260738, God bless you all  

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