The first thing that should catch the provider’s eye in this ECG is the presence of ST segment elevation in the inferior leads (II, III, aVF). This unfortunate patient is experiencing extension of the infarction into the back side, or posterior wall, of the heart. Posterior wall injury occurs in isolation approximately 5% of the time and is usually seen in conjunction with an inferior wall MI. That said, never dismiss ST segment depression in leads V1 and V2 as a non-STEMI! If you were to place ECG leads on this patient’s back, leads V1 and V2 would show ELEVATION. You can recognize posterior wall MI by:
-Tall R waves
-ST segment depression in V1 and V2
Upright, tall R waves are present in V2. Tall R waves aren’t usually seen in those two leads. In conjunction with ST segment depression, they represent a posterior wall STEMI!
Here’s another ECG depicting posterior wall (and inferior wall!) injury:
Again, R waves are positively deflected (upright) in V1 and V2. ST depression and upright T waves are also present.
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