1. Acute Posterior Wall MI (V1-V2)
• EKG changes in V1, V2 (tall R waves;
“early transition”, ST
depressions, upright T waves)
• Due to usual etiology of RCA
occlusion, often associated with
inferior MI
• Increased morbidity/mortality
compared with isolated IMI
• Consider R sided (look for ST elevation
in rV4) or POSTERIOR leads (V7,8,9,…)
– continue placing leads around to
posterior CW under axilla until you
reach the spine

2. Acute Posterior Wall MI

3. Acute Posterior Wall MI
(posterior leads)

4. Acute Inferior MI with Posterior
involvement

5. Acute R-sided MI (RV)
• Often associated with inferior or
posterior MI
• May be isolated (1 mm ST elevation in
avR, or V1-V2)
• More common in pts with chronic lung
dz and RVH
• Commonly associated with RBBB

6. Acute R-sided MI (RV)

7. Acute Inferior/R-sided MI

9. Predominantly LCA lesions
• Anterior MI
• Lateral MI
• “High Lateral” MI

10. Anterior MI
• Due to lesions further down the LAD
• ST elevation in anterior precordial leads
V3-V4 (may also be V2-V5)
• If lateral wall involvement, then ST
elevation also seen in 1, avL, V6

11. Anterior MI

12. Anterior MI

13. Anterolateral MI

14. Anterolateral MI

15. “High Lateral” MI
• Due to lesions of the LCx artery, more
distally
• ST elevations isolated to I, avL
• May only see T wave inversions in L
(subtle!!!)

16. “High Lateral” MI

17. “High Lateral” MI

18. “High Lateral” MI

19. Septal wall MI
• Septal MI typically shows ST
elevation, Q waves, and inverted T
waves in the leads overlying the
septum (V1-V3)

20. Septal wall MI

21. Lateral wall MI
• Usually LAD lesions prior to take-off of
L circumflex artery
• Often with septal and anterior
involvement, or inferior depending on
the patient’s anatomy
• May see isolated lateral MI with more
distal lesions (rare)

22. Lateral wall MI

24. Acute Coronary Syndrome
Care - prehospital
• All cases should receive ASA 325
mg, unless taken PTA, or allergy, or
bleeding/on coumadin (document)
• IV x 2, O2, monitor
• “MONA”;
morphine, oxygen, nitrates, aspirin
• NTG SL (400 mcg, beware hypotension)
• Other protocol?

25. Acute Coronary Syndrome
Care - hospital
• NTG drip (10-20 mcg/min, titratable)
• Plavix 600 mg PO if going for cath (300
mg otherwise)
• Heparinization
• If large MI, cardiogenic shock
– Vasopressors (dopamine/dobutamine)
– Intra-aortic balloon pump

26. PCI inclusion criteria
• Age 18-85
• CP > 20 min & < 12 hrs
• ST elevation > 2mm or New LBBB
• Ability to cooperate / consent
• Weight < 350 lbs
• Non-pregnant
• No Hx of anaphylaxis

28. Part III: Interesting EKGs and
Tox

29. Case 1: history
• You are called to the local 7-11 for a female not
feeling well. She appears pale as she smokes a
cigarette and drinks her Slurpee. Her VS are BP
94/60, HR 70, RR 12, T 38.0, and R/A pOx 99%
• She tells you that she hasn’t been feeling well
for at least a week and has burning pain in her
mid-chest, and she can’t sleep because the
pain is horrible at night
• On exam she has clear lungs, no murmurs, but
you think you might hear a rub along the L
sternal border
• She has a faint, reticular pink rash on her torso
that she hadn’t even noticed until you point it
out to her

30. Case 1 EKG

31. Case 1: Pericarditis
• Causes
– Viral (coxsackie, echovirus, HIV), bacterial
(staph and strep), malignancy, rheumatic
diseases, myxedema, uremia, s/p MI, s/p
XRT
• EKG findings
– “Diffuse” ST elevation
– PR segment depression
– ? Notching of J point
– Sinus tachycardia

33. Case 2
• You are called to the West Warwick PD
for a 30 y/o incarcerated male who
briefly collapsed in the holding cell.
The police think he was faking it and
tell the you he has a h/o drug problems
and psychiatric issues.
• You decide to get a 12-lead EKG on the
patient, who is now coming around

34. Case 2 EKG

35. Case 2: Brugada syndrome
• Brugada syndrome
– Sodium channel abnormality causing
abnormal ventricular repolarization
– Risk of R on T phenomenon, VT/VF and
sudden death
– AICD needed