ECG Challenge – Is it a STEMI?

Since you all seemed to enjoy the link I posted to the ACC's ECG Challenge from 2006 I thought I'd give you another ECG Challenge.

I'm working on a special project (details to be announced soon) and I came across this interesting ECG from the archives of an old computer.

I thought it was long lost! At least the original un-cropped version.

This is one of the very first ECGs transmitted across our first LIFENET system (many years ago).

Let us assume that the patient is experiencing signs and symptoms consistent with ACS.

Does it show acute STEMI? No cheating if you've seen this before! 

(Note: Lead V4 is in the position of lead V4R.)


  • Pete Murrell says:

    It would appear that aVF is showing some ST elevation.
    I am interested to hear the thoughts of people who know though. I am very new to ECG and want to learn more about them.

  • i.v says:

    no receprocation depresions and there are modorate elevations on almoust all leads so iwould think maybe perecarditis 

  • liz says:

    I see elevation in II, III, aVF, V5, V6. Despite reciprocal changes, I'd still feel comfortable calling it an inferior-lateral STEMI and activating the cath lab. I'd guess left circumflex is the culprit.

  • Newer EMT-I says:

    Seeing elevation in 2/3/AVF…inverted T's in 3…no reciprocol…but with SS consistant with ACS and that strip…I would call a STEMI and let the doc's prove or disprove it.  

  • Hatch says:

    II, III, and aVF as well as V5 and V6. I'm not seeing any reciprocal changes but according to our protocol I'd call it a STEMI and take them to an apropriate facility. This is kind of a tough one out in the field but it's better to be on the safe side.

  • schmidty says:

    i would call it an acute stemi because it for sure fits under our protocols, and because the elevation  has two or more consecutive leads with greater that a 1 mm increase.  better to think the worst and be wrong than to go routine and have it be one. 

  • Alex says:

    Im with Liz,  Inferior-lateral MI alert

  • KristenEMTRN says:

    Per most ACLS protocols you could call a STEMI based on the pts presentation, and the 1mm of elevation on II III avF- inferior infarct, however the ST elevation on V5 V6 is only 1mm and must be 2mm to consider infarct in the percorial leads (as I was recently informed by an ER doc). To be noted as well the pt probably has hyperkalemia as noted by the flattened P waves, and peaked T waves that are at least half the height of the QRS, and the noted slight bradycardia. If there is an acute coronary thrombus I would predict mid to distal RCA.

  • i.v.,

    What about V1, looks like some ST-depression there.

  • Medic Jesse says:

    Considering that the patient is presenting with s/s consistent with ACS I would treat for STEMI. It is possible that this could be pericarditis but that would not change the treatment modality at all.   I would transmit the 12 lead and treat to ACLS CP Protocol with rapid transport to a STEMI center. Let the cardiologist/ED Doc figure it out.  Better to over treat this than to not. 

  • Kristen,

    What the ED doc was likely referring to is elevation in the right precordials (V2-V3) which have different cutoffs for men (by age) and women:

    • – Men (<40yo): ≥2.5mm V2/V3, ≥1mm V1/V4-V6
    • – Men (≥40yo): ≥2mm V2/V3, ≥1mm V1/V4-V6
    • – Women: ≥1.5mm V2/V3, ≥1mm V1/V4-V6
  • arnel says:

    Sinus bradycardia, ST elevations in 2/3/aVF,V5 and V6, some degree of peaking of the T wave in V2. ST elvevation 2>3, no ST dep in 1 and aVL, no STE in V4R, no PR elevations. With associated SS agree with most postings could be STEMI. Culprit artery could be LCx based on some fulfilled criteria – STE 2>3, no reciprocal change in aVL

  • billy says:

    IM calling it inferolateral stemi also.. diff. is pericaditis.

  • Duncan Campbell says:

    Acute STEMI until proven otherwise, always err on the side of caution till proven otherwise, sure it could be pericaritis, does it really matter, your treatment modalities should be per ACLS, for any medic in the field that would be a STEMI.

  • BigWoodsMedic says:

    ST elevation in II, III, aVF, V5/V6, also noting there is slight depression of V1 and V4R. I was under the impression that V4R requires less movement either way to be called elevation or depression. The peaked T-waves are troublesome too, so STEMI, pericarditis, hyperkalemia. There really isn't enough information for me to determine further. I'd be sending this to the ER and consulting with med command for a STEMI alert based on the EKG and standard ACS presentation.

  • Juzny Alkatiri says:

    No doubt…Inferior STEMI

  • ssaul says:

    I would go with STEMI even without the reciprocal, given the ACS s/s.

  • DaveOC says:

    There is ST depression in that lead v4R. Wouldn't  that be reciprocal to lateral elevation ? or no ?
    I'd call it a STEMI.

  • Brad J says:

    Bottom line is that it meets critia for an inferior-lateral stemi. Elevation noted in II, III, AVF, V5, V6. Sure there are no reciprocal changes, but what litature says there HAS to be? Pericarditis? Are you willing to bet your Certification on that bc every time I’ve seen pericarditis it’s elevation in every single lead. I also think that the only reason people are questioning the MI is bc he made the title sound tricky and now it’s got everyone second guessing. Are you going to get in trouble or do harm to the patient for calling it an MI, absolutely not. Are you going to get in trouble or do harm to the patient if you DON’T call it an MI, ABSOLUTELY.

  • Shalom says:

    Could be pericarditis: lot of ST elevation, PR depressed
    but on the other hand: seems to be ST depression in V1 which is strange for pericarditis, and ST segments are mostly frowney and straight(especially in III and AVF which seem unusual for peri).
     Also when Tom discussed RVI he brought an image that showed ST depression in V4R  hinting to LCX occlusion, another table saying that a proximal LCX occlusion may have ST elevation in I AVL and that STE in II will be bigger than STE in III(and all of these occur in the above ecg)
    Anyway, if the symptoms are consistent with ACS treat as MI…

  • baker says:

    For the sake of the pt. And the fact that im not a cardiologist I would call it a Stemi and transport to a cath facility, but I would almost guarantee its pericarditis.

  • Brad J says:

    ^^^^ Why is that?

  • baker says:

    ^^^ Because he has widespread elevation except for leads V1,V2,V4,  which V1, V2 would normally be depressed as they are in this ekg if the pt were to be having a posterior MI, so basically the entire ekg appears to be one giant MI.  One of the big giveaways for pericarditis is global elevation which is pretty much what you are seeing here,  also there is no consistent pattern on this ekg what i mean by that is that the reciprocal changes dont match up with any of the areas that are elevated,  there are no inverted T waves and there are no Q waves of any magnitude. That is my reasoning behind calling it pericarditis,  but i am younger medic so i would take advice from some of the more experienced   medics on this page as well.

  • David Baumrind says:


    so, if are going to say that there is no ST elevation in leads V1-V4, can we really say it is "global"?

    also, regarding the ST depression in V1… should pericarditis have ST depression anywhere (other than aVR)?

  • Baker,

    Inspection of the TP segments show that I and aVL appear to have isoelectric J-points while II/III/aVF have clear ST-elevation. V1 may be isoelectric or have ~0.5mm ST-depression, V2-V4 appear relatively isoelectric, and V5-V6 have obvious ST-elevation.

    This appears to be an inferiolateral pattern, but I can see how I and aVL may look elevated.

    Also, don’t discount your read just because you’re a newer medic! Cold reads like this are tough because we lack the “look” of the patient to guide our diagnosis.

  • jeff says:

    Just because there is no recpricol  changes does not mean its not an acute MI at all.  There is elevation in two or more contigious leads and we as paramedics must treat this as a STEMI pt.  Even w/o the elevation, just on presentation alone he gets the acs rx.  

  • David Baumrind says:

    also, just to add to what Christopher said, the difficulty is compounded because the usual ST depression we would see in aVL reciprocal to inferior ST elevation may be "dragged up" by the lateral ST elevation, making aVL look isoelectric.. ST depression in V1 plus tall R waves in V2 and V3 may also be suspicious.

  • Dave S says:

    pericarditis= no stemi, but the cath lab will generally be required to prove or disprove this diagnosis of exclusion.

  • VinceD says:

    Hmm I think I remember you mentioning this ECG before (the fact that it was one of the first transmitted) but I can't remember the outcome…

    I'm saying STEMI. Elevation II,III,aVF, V5, V6 with depression in V1 and V4R and terminal T-wave inversion in aVF. I'm trying to decide if that tall T-wave in V-2 is pathological (hyperacute) and I'm leaning towards no since there's an awfully tall R-wave in front of it. On that subject, there's an extremely early R-wave transition in the precordials, but I'm thinking that's due to placement more than anything else since the QRS complex in V1 appears normal, however it's worth noting and could be masking depression that would be seen in a normally positioned V2, further clinching the diagnosis.

  • Brad j says:

    Yes, I know criteria for pericarditis, but I wanted to know your reasoning. As I said before typically pericarditis is elevation in ALL leads. Have you never seen a inferiorlateral MI, or anteroseptal MI? Not uncommon to infarct in different areas of the heart at the same time…. Don’t discredit your self as a “younger medic” I’m 27 and have only been a medic 2 1/2 years, but that doesn’t mean that we’re not capable of being great medics. I also have my critical care paramedic so that helps with confidence too. Just because someone is older doesn’t mean they’re better. 😉

  • Brad J says:

    Also, you mentioned posterior mi is depression in V1-V2. True, but remember septal MI’s will be elevated in V1-V2….. There’s no elevation in V3 either. That’s a peaked T wave, so there is no elevation in V1-V4. That’s four out of 12 leads and AVR is not a good lead for diagnosing so do you still think percarditis? I could very well be wrong, but I would call this an MI 10/10 times, especially with a presentation of ACS.

  • Ben says:

    Wanted to point out….the inferior and lateral walls ARE the reciprocal areas of the LV, so if both are elevated you'll never get your reciprocal ST depression 🙂  I'd go with STEMI and cath lab alert as well…I can't remember for sure, but I think I recall being told that the "2mm rule" for ST elevation was originally proposed as a criteria for thrombolytic therapy (but double check before you quote me on that one!), not for clinical significance.  Coupled with s/sx of ACS, I'd treat ST elevation less than 2mm the same way.
    To raise another observation…the R-wave progression is a bit off as well.  Looks like the Z-axis is about 10 degrees anterior.  There's flat ST depression in V1 as well, I'd be thinking really hard about looking at posterior leads for posterior wall involvement.  An anterior Z-axis either indicates more myocyte transmission in the anterior areas, or less electrical activity in the posterior ones.  I don't see any real evidence of left ventricular hypertrophy, so I'm suspicious for posterior ischemia/infarction.

  • Brad J says:

    ^^^^ Exactly! I’ll be honest even knowing that the lateral leads were reciprocal to inferior leads I complete tunnel vision’d on the MI and didn’t even think of that. Strong work, Ben.

  • Paramedic Pete says:

    Almost certainly pericarditis. Signs of global ischaemia and therefor this patient has no/ or hardly any  perfusion from any coronary arteries and should therefor be dead. This patient should still be treated by the same as any other cardiac patient,as there is still significant mortality from pericarditis. Well done to the newer medic. One of the classic false positives that cath labs so love. Had a 90 year old  patient a few weeks ago with similar ECG, as an emergency transfer. She looked far too well for that ECG though and the pain was reduced by sitting up ( classic sign). The Cardiologist was happy to listen to our concerns and didn't go through with the Angio. As always look at both the patient and ECG. Take care, Pete.

  • medic-dawg says:

    This is why the ER has an Echo machine!
    I'm on the pericarditis boat also.

  • Adam Stevenson says:

    STEMI! STE in II, III and AVF. V4R showing ST depression and T wave inversion which all points towards occlusion of the LCX. 

  • Baker says:

    I appreciate all the input on my post Brad J.  and everyone else that had input as well,  you all pointed out interesting things that i will take into consideration when looking at 12-leads.

  • GregNFD says:

    Electrocardiogram (EKG). EKG changes in acute pericarditis mainly indicates inflammation of the epicardium (the layer directly surrounding the heart), since the fibrous pericardium is electrically inert. For example, in uremia, there is no inflammation in the epicardium, only fibrin deposition, and therefore the EKG in uremic pericarditis will be normal. Typical EKG changes in acute pericarditis includes[7][2]

    stage 1 — diffuse, positive, ST elevations with reciprocal ST depression in aVR and V1. Elevation of PR segment in aVR and depression of PR in other leads especially left heart V5, V6 leads indicates atrial injury.


  • Josh says:

    whats the answer tom?

  • I would say STEMI, and transport to the local PCI center. While I agree, there are no reciprocals so at first glance I would say this is a "Possible STEMI" instead of "Definate STEMI." I am concerned about V4R, with the flattened T Waves and apparently prolonged QT segments, combined with the Inferior Infarction, I would say this is an extremely acute 12-Lead and would treat as aggresively as possible. I do not think it is as simple as pericarditis

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