Myocardial
Ischemia /
Localization on ECG Injury /
Infarction
2
ECG
Chief diagnostic tool to identify
Using ECG one can localize the site of Ischemia / Injury/ Infarction.
3
Why Localize ?
EVOLUTION OF ECG
DURING STEMI
1) Hyper acute phase
- tall symmetrical ,peaked,wide base t wave
- slope elevation of st segment
2) Evolved phase
- appearance of Q wave
- j point elevation (< then hyperacute phase)
- decrease r wave height
- t wave inversion
3) chronic stable phase –
- persistance of q wave
- st return to baseline
-t wave becomes normal
5
SURFACES OF HEART
Anterior:Right Inferior/Diaphragmatic:
atrium, Right 2/3 by LV&1/3 by
ventricle and RV.
partly by LV,LA.
LEFT: Left
ventricle, Left
Auricle
6
Dr. UZMA ANSARI
7
9
Blood supply
RCA LCA
Larger
Smaller
Lt post aortic sinus
Ant aortic sinus LA
RA LV except area around
RV except area around posterior IV groove
anterior I V groove Anterior I V septum
Posterior I V Septum RV: small area around
LV:small area around anterior IV groove
Part of LBB
posterior IV groove
Entire conducting system
LMCA Entire LV, LA, except the posterior portion of IV
septal and adjacent area when PD is a branch of
RCA
LAD • Anterior 2/3rd of IV septal
• Anterior portion of LV
• Whole apex
1st D (Branch of High lateral wall of LV
LAD)
2nd D Lower lateral aspect of LV free wall
1st Septal Superior and Anterior portion of IV septal
Minor Septal Inferior and anterior 1/3rd of septum
Ramus Inter Anterior aspect of apex
ventricularis
(From LCA)
LCX • 97% from LCA Obtuse margin of
• 2% from Separate heart and entire
Ostium posterior wall. LA,
• 1% RCA posterior IV septum
if PD arises from LCX
OM • 97% LCA Obtuse margin of
heart adjacent to LV
Postero • 80% LCA Posterior and
lateral branch • 20% RCA diaphragm LV wall
PD • 82% RCA Posterior IV septum
• 18% LCA and Diaphragm LV
RCA RA and part of LA, RV,
Posterio superior IV
septum. SN, AV node
Acute Marginal Inferior and diaphragmatic
surface of RV
Conus Branch Outflow track of RV
SN branch RA, LA,SN
RV Branch RV
Atrial Branch Right Atrium
Localization - Left Coronary Artery
(LCA)
Dr. UZMA ANSARI
Localization
Right Coronary Artery (RCA)
Dr. UZMA ANSARI
15
Localization Summary
Dr. UZMA ANSARI
Prevalence of Culprit Artery
RCA 45%
57%
LCX 12%
LAD 36%
Post Ischemic T wave
changes
ST elevation MI Non-ST Elevation
Infarction
ST depression
Ischemia ST depression, peaked & T-wave
T-waves, then T-wave Ischemia inversion
inversion
Infarction ST elevation & Infarction ST depression &
appearance of Q-waves T-wave inversion
ST segments and T-waves Fibrosis ST returns to
Fibrosis return to normal, but Q-
baseline, but T-
waves persist
wave inversion
persists
Localization
The changes of ischemia/injury/infarction are seen in the leads
Over lying the area involved
I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
Dr. UZMA ANSARI
Localization
I aVR V1 V4 Inferior: II, III, AVF
Septal: V1, V2
II aVL V2 V5
Anterior: V3, V4
III aVF V3 V6 Lateral: I,Dr.AVL, V5, V6
UZMA ANSARI
Localization - Myocardial Infarct
Reciprocal
Localization ST elevation Coronary Artery
ST depression
Anterior MI V3-V4 None LAD
Septal MI V1-V2 none LAD
II,III, aVF (inferior
Lateral MI I, aVL, V5, V6 LCX
leads)
RCA (80%) or LCX
Inferior MI II, III, aVF I, aVL (lateral lead)
(20%)
Tall R in V1-V3 with ST
Posterior MI V7, V8, V9 depression V1-V3 > RCA or LCX
2mm (mirror view)
Right Ventricle MI V1, V4R I, aVL RCA
The localisation of the occlusion can be adequately visualized
using a coronary angiogram (CAG).
Anterior Wall
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Septal
V1, V2
◦ septum is left
ventricular tissue
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Septal Wall
V1, V2
◦ Along sternal borders
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Practice
Anteroseptal MI
ST elevations V1, V2, V3,
V4
Lateral Wall
I and aVL
◦ View from Left Arm
◦ lateral wall of left ventricle
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Lateral Wall
V5 and V6
◦ Left lateral chest
◦ lateral wall of left ventricle
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Lateral Wall
I, aVL, V5, V6
ST elevation suspect lateral wall
injury
Lateral Wall
29
Lateral MI
Localization - Extensive Anterior
MI
Dr. UZMA ANSARI
Anterior MI with lateral
involvement
ST elevations V2, V3, V4
ST elevations II, AVL, V5
Inferior Wall
II, III, aVF
◦ View from Left Leg
◦ inferior wall of left ventricle
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Inferior MI
Practice 3
Inferior MI
ST elevation 2,3 AVF
Inferior lateral MI
ST elevations 2, 3, AVF
ST elevations V5
Posterior Leads
Posterior leads V1, V2
Posterior Infarct with ST
Depressions and/ tall R wave
RCA and/or LCX Artery
ST elevation in V7,V8,V9.
Understand Reciprocal changes
The posterior aspect of the heart
is viewed as a mirror image and
therefore depressions versus
elevations indicate MI
Rarely by itself usually in combo.
Dr. UZMA ANSARI
Localization Criteria:
Occluded artery to the ECG
Source: AHA
Anterior wall MI
Occlusion of LAD
ST , V1-V6
Occlusion above D1 and 1st Septal
Basal portion of LV
Anterior and lateral wall
Inter-Ventricular Septum
ST segment vector – superiorly and to left
ST elevation ST depression
V1-V4, lead I, aVL, often II, III, aVF (Inferior) often
in aVR V5
aVL > aVR III > II Dr. UZMA ANSARI
• During acute AWMI, the maximal ST-segment elevation is best
recorded in V2 or V3; V2 is the most sensitive lead to record ST-
segment elevation (sensitivity 99%) and to identify the culprit
lesion at the LAD.
• Lead V1 captures electrical phenomena from the right paraseptal
area, which has dual blood supply by the septal branches of the
LAD and by the conal branch of the RCA. This is the reason why
patients with AWMI may have no ST-segment elevation in V1.
New RBBB with a Q wave preceding the R
wave in lead V1 is a specific but
insensitive marker of proximal occlusion
of the LAD artery in association with
anteroseptal myocardial infarction.
Occlusion: Between 1st Septal and
D1
Occlusion: More distally i.e.
below Septal 1 and D1
Basal portion spared (ST vector directed inferiorly)
ST segment not elevated in I, aVL/aVR
No depression in II, III, aVF
Indeed, ST segment elevation in II, III, aVF
ST segment elevation more prominent in V3 – V6 than V2
Dr. UZMA ANSARI
Recommendation
LAD OCCLUSION PROXIMAL TO D1
Inferior MI
ST Elevation in II,III,aVF
RCA OR LCX
ST III>II ST II>III
ST I,aVL ST I,aVL
Proximal RCA
V4R
1.Most commonly used right sided
Right Ventricular lead
2.Great value in diagnosing RV infarct
Ischemia / along with IWMI
Infarction 3.Useful in distinguishing between RCA
and LCX involvement
4.Between proximal and distal RCA
occlusion
5.V3R, V4R should be recorded as
ST elevation in right
rapidly as possible because ST
anterior leads i.e. V3R,
elevation in V3R, V4R remain for a
V4R, sometimes V1 shorter period of time in RWMI than
ST elevation in extremity leads (II,III,
40% Associated with aVF) in inferior MI
inferior M.I.ST elevation-
V3R,V4R,V1,II,III,aVF
RCA (DISTAL) OCCLUSION
RCA (PROXIMAL) OCCLUSION
Inferior MI +Posterior M.I.
Proximal RCA OR LCX
(posterior+inferior) Posterior+Inferior MI
+ RV infarct
ST
II,III,aVF,aVL,I ST II,III,aVF
ST ,tall R V1,V2,V3,
ST I,aVL ST II>III
ST V3R,V4R
ST III>II
May 22, 2025January
58
2004
Dr. UZMA ANSARI
• ST-segment elevation in lead aVR can be caused by :
(1) Global subendocardial ischemia caused by left main trunk or 3 vessel
disease
(2) Transmural ischemia in the basal part of the interventricular septum
caused by impaired coronary blood flow of the first major branch
originating from the LAD artery.
(3) Transmural ischemia in the right ventricular outflow tract caused by
impaired coronary blood flow of the large conal branch originating
from the RCA.
(4) Reciprocal changes opposite to ischemic or non-ischemic ST-segment
depression in the lateral limb and precordial leads.
Thank You
