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Isolated posterior STEMI is the most commonly missed STEMI! It is estimated that ~ 4-10% of STEMI's are isolated posterior MIs.
ST elevation is typically not seen on the standard 12-lead ECG in isolated posterior STEMI, commonly leading to misdiagnosis as "anterior ischemia or NSTEMI". The following summarizes the most recent ACC/AHA & ESC guidelines :
Posterior (“inferolateral” or “inferobasal”) STEMI
Posterior (“inferolateral” or “inferobasal”) STEMI
Recording posterior leads is recommended in patients with high clinical suspicion of acute left circumflex occlusion (e.g. initial ECG non-diagnostic or ST segment depression in V1-V3)
Isolated ST depression ≥ 0.5 mm in leads V1-V3 may indicate left circumflex occlusion (especially when the terminal T wave is positive) and can be captured using posterior leads (place V7 at the 5th intercostal space over the left posterior axillary line, V8 at the left mid-scapular line, and V9 at the left parasternal border)
ST segment elevation (≥ 0.5 mm) in posterior leads V7-V9 is diagnostic; however, specificity is increased at a cut-off point of ≥ 1.0 mm (should be used in men < 40 years old)
KEY PEARL:
KEY PEARL:
In both men and women (all ages), STE in V7-V9 ≥ 0.5 mm meets ECG STEMI criteria.
References:
Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol 2018;72(18):2231–64. PMID: 3015396
Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2017;39(2):119–77. PMID: 28886621
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