Epigastric pain and ST depression in V1–V3
A 56-year-old woman with type 2 diabetes attends the emergency department with nausea, vomiting, and epigastric discomfort that began 2 hours ago. She denies classic central chest pain and says the discomfort feels like indigestion. Her blood pressure is 148/88 mmHg, heart rate 102/min, and oxygen saturation 97% on room air. A 12-lead ECG is recorded. The technician notes ST depression of about 2 mm in leads V1–V3, a tall R wave in V2, and upright T waves in V2–V3. The automated interpretation reads 'non-specific ST-T changes; no acute myocardial infarction.' The emergency physician is with a trauma patient and asks the technician to hand over the tracing for later review. She has no known cardiac history and takes metformin only. The technician has been trained to record posterior and right-sided leads but has not yet used them in this department.
1. Interpret the V1–V3 findings and explain why the automated report is misleading.
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The combination of ST depression in V1–V3, a tall R wave in V2, and upright T waves is a classic reciprocal pattern of posterior myocardial injury. The posterior wall is electrically opposite to V1–V3, so posterior ST elevation appears as anterior ST depression. The tall R in V2 is the reciprocal of a posterior Q wave. The automated report is misleading because it has not recognised the regional pattern and has labelled the changes 'non-specific.' In a diabetic woman with nausea and epigastric discomfort, atypical presentation does not make the ECG benign. The technician should treat this as a suspected acute coronary syndrome until a clinician reviews it.
2. What additional leads and immediate actions should the technician take?
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Record posterior leads V7–V9 and, because posterior infarction often accompanies inferior infarction, also check the inferior leads and consider right-sided leads V3R–V4R if inferior changes are present. Label the additional leads clearly and repeat the standard 12-lead ECG. Look for ST elevation in V7–V9; even small elevation can support posterior injury. Do not simply hand over the tracing for later review. Escalate to the emergency physician or nurse in charge now, stating: 'Anterior ST depression with tall R in V2, suspected posterior MI, additional leads requested.' Keep the patient on cardiac monitoring and document the time of escalation.
3. What pitfalls should the technician avoid in this scenario?
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Avoid dismissing the ECG because the automated interpretation says 'no acute myocardial infarction.' Avoid assuming the symptoms are indigestion because the patient denies classic chest pain; diabetic and female patients often present atypically. Avoid recording only the standard 12 leads and stopping when the doctor is busy. Avoid mislabelling the anterior ST depression as anterior ischaemia without considering posterior infarction. Ensure correct lead placement and good-quality tracings, but do not let technical perfection delay urgent escalation. The technician should present the findings factually and let the clinician decide management.