A study in EMJ suggests we aren’t good enough at identifying posterior myocardial infarctions (PMI). That is unfortunate. The hemodynamic consequences can be severe if given time to develop. And importantly, if we don’t recognize it as the STEMI it is, then optimal treatment (PCI) will be delayed.

When confronted with a 12-lead ECG with ST-depressions in the anterior leads V1-V2 and possibly a dominant R-wave in V1-V2, the emergency medicine professional should suspect a posterior myocardial infarction.

Since the conventional 12-lead ECG doesn’t directly view the posterior wall, the next action should be to apply posterior leads. If there is ST-elevation in the posterior leads (V7-V9) it should be considered a STEMI and the patient should be on his way to the cath lab.

The Study

 According to the study in EMJ we don’t get it right as often as we would like to think.

A number of ED doctors (Cardiologists were excluded) and paramedics were confronted with the ECG to the right in the context of chest pain in a fictional case.

They were expected to identify the possibility of a PMI and then, as the next step, move on to obtaining posterior leads in order to confirm the diagnosis.

The results are a bit unsettling:

Not so good.

Especially as there is no apparent reason to believe we would do any better in the place I work at the moment. Strange too. After all, this is med school stuff. Is this the result of years and years of trusting the machine to interpret our ECGs?

Find the study here.


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