Inferior MI: Reciprocal Changes & Remote Ischæmia

Report:

Sinus rhythm 71/min

Acute inferior infarction

Comment:

The reciprocal changes, although minuscule in 1 and very modest in aVL, are spread through all the chest leads. This is now thought to reflect a large infarction rather than separate, remote ischæmia1. However, in 24 hours (Fig 1a below) the indicative changes have dwindled to 1 mm ST elevation in 3 while the reciprocal depression is still going strong. It may well be that, in this case, some of it does represent remote ischæmia or infarction, at least in the anterolateral leads. The troponin level peaked, on second day, at 25 µg/L (N < 0.4 µ/L).

The ECG below (Fig 1a) is also a good example of a positive concordant pattern in the frequent VEBs: despite small S waves, they are, collectively, positive enough and concordant enough to preclude aberrancy. If the VEBs were aberrant, they’d have to be standard + precordial masquerading bundle branch block type; the only thing that would swing me to that exotic view would be definite P’ waves!