ECG Findings
• With acute injury pattern—ST segment depression in lead V1 and/or V2 with acute injury pattern
• With infarction pattern—Small S wave and large R wave greater than 4 ms duration in lead V1 or V2 with infarction
• With infarction pattern—R-wave/S-wave ratio greater than 1 in lead V1 or V2 with infarction.
Important Learning Points:
1. The posterior portion of the left ventricle has no EKG electrodes directly overlying it and is the last portion of ventricle to depolarize. It receives its blood supply from either the right coronary artery (in 85% of individuals) or the circumflex artery (in 15% of individuals).
2. V1 and V2 are primarily affected as the most anterior leads and indirectly assess the posterior left ventricle, though in an “inverted” orientation. Instead of observing downgoing Q waves and ST elevation, one expects to see large upgoing R waves and ST depression. By holding the EKG
up to a backlight upside down and horizontally flipped, the more classic injury pattern can be observed by looking through the EKG paper (see picture below).
3. Posterior involvement may be confirmed with posterior leads. V8 is located at inferior tip of left scapula; V9 is positioned between V8 and the spine at the same level.
4. Frequently, an inferior MI is also present with a posterior MI, since the right coronary artery serves both areas. In the above example, there is subtle ST elevation in the lateral leads, indicating posterior-lateral injury.
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