This document discusses various ECG patterns seen in myocardial infarctions. It provides detailed descriptions and examples of ECG findings associated with anterior MIs, anteroseptal MIs, anterolateral MIs, extensive anterior MIs, right ventricular MIs, inferoposterolateral MIs, LMCA occlusions, de Winter's T waves, acute MIs with right bundle branch blocks, and inferior and posterior STEMIs. The document aims to help clinicians interpret ECGs and identify which coronary arteries may be occluded based on the ECG patterns.

1. Title ?????
Dr. Vinod Sharma
National Heart Institute
New Delhi
1

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

14. 14

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 21

22. 22

23. 23

24. 24

26. 26

29. 29

31. 31

32. 32

33. 33

34. 34

35. 35

36. 36

37. 37

40. 40

41. 41

42. 42

43. Pathologic Q wave Criteria
“Classic” criteria
• Q-wave with a duration ≥40 ms and/or a
depth ≥25% of the R-wave in the same lead
or the presence of a Q-wave equivalent 43

44. 44

46. 46

47. Anterior MI Pattern - Tombstoning
47

48. Tombstoning in Lead V2 – Septal
involvement
48

49. 49

50. Anteroseptal MI
50

51. 51

52. 52

54. 54

55. Anterolateral MI
55

56. Extensive Anterior MI
56

57. 57

59. 59

61. 61

62. 62

63. RV Myocardial infarction
63

64. Value of Lead V4R in Acute Inferior MI
Lead V4R identifies:-
• The coronary artery occluded
• Presence or absence of right ventricular
infarction.
• Those at risk for atrioventricular (AV) block
• Those who will profit most from thrombolytic
therapy
64

65. 65

66. 66

67. 67

68. 68

69. 69

70. 70

71. 71

72. 72

73. Inferoposterolateral MI
73

74. 74

75. 75

76. 76

79. LMCA Occlusion Overview
Typical ECG findings with left main coronary
artery (LMCA) occlusion:
• Widespread horizontal ST depression, most
prominent in leads I, II and V4-6
• ST elevation in aVR ≥ 1mm
• ST elevation in aVR ≥ V1
79

80. ST elevation in aVR
80

81. De Winter’s T Waves
Clinical Significance of De Winter’s T Waves
• The de Winter ECG pattern is an anterior STEMI
equivalent that presents without obvious ST
segment elevation.
• Key diagnostic features include ST
depression and peaked T waves in the precordial
leads.
• The de Winter pattern is seen in ~2% of acute LAD
occlusions and is under-recognised by clinicians.
81

82. De Winter’s T Waves
82

83. De Winter’s T Waves
Diagnostic Criteria
• Tall, prominent, symmetric T waves in the precordial leads
• Up sloping ST segment depression >1mm at the J-point in
the precordial leads
• Absence of ST elevation in the precordial leads
• ST segment elevation (0.5mm-1mm) in aVR
• “Normal” STEMI morphology may precede or follow the
deWinter pattern
Original reports of the de Winter pattern suggested that the
ECG did not change or evolve until the culprit artery had
been opened. Since then, cases have been reported where
the deWinter pattern evolved from, or evolved to a “classic”
anterior STEMI.
83

84. De Winter’s T Waves
84

85. De Winter’s T waves
• Upsloping ST depression in the precordial leads (>
1mm at J-point).
• Peaked anterior T waves (V2-6), with the
ascending limb of the T wave commencing below
the isoelectric baseline.
• Subtle ST elevation in aVR > 0.5mm.
There is also some high lateral involvement, with
subtle ST elevation in aVL plus reciprocal change
in III + aVF. This is consistent with LAD occlusion
occurring proximal to the 1st diagonal.
85

86. De Winter’s T waves
86

87. De Winter’s T waves
87

88. 88

89. 89

90. 90

91. Acute MI with a RBBB
91

92. Acute MI with a RBBB
92

93. Inferior Posterior STEMI
93

94. Inferior Posterior STEMI
94

95. Inferior STEMI
95

96. Inferior STEMI
96

97. Inferior STEMI
97

98. Anterior MI – Isolated J point Elevation
98