51 y/o M with a hx of smoking and HTN presents with acute onset of chest pain….



Is this anteroseptal ischemia or posterior MI?

Some clues to help identify the posterior STEMI:

  1. The triad of ST depressions, upright Ts, and tall R waves (basically the equivalent of Q-waves)

  2. Do a posterior EKG!



  • You only need 0.5mm elevation in the posterior leads (v7-v9) to make the dx


Posterior MI

  • Most common type of missed MI

  • often misdiagnosed as NSTEMI

  • Only 30% are revascularized in 90 minutes

  • Usually associated with inferior or lateral MI due to RCA or circumflex occlusion

  • 4-10% of STEMIs are isolated posterior STEMI


Amal Mattu’s posterior MI Pearls

Dr. Steve Smith’s ECG blog