Pseudoinfarction pattern by misplacement of electrocardiographic precordial leads

Brugada Syndrome: Diagnostic Pitfalls

“…There are also reported occurrences of upward misplacement of leads V1 and V2 resulting in apparent "ST elevation," as well as Twave inversion, in lead V2 that can mimic a septal injury pattern (6). Superiorly misplaced right precordial leads also can record RSR' complexes mimicking incomplete right bundle branch block (7).…”

ST-segment elevation in non-atherosclerotic coronaries: a brief overview

“…Too high or too low precordial leads misplacement can cause significant ST-T deviation [8]. A high lead, shifted even by 2 cm can produce an ECG mimicking an AMI.…”

Proposed Bedside Maneuver to Facilitate Accurate Anatomic Orientation for Correct Positioning of ECG Precordial Leads V1 and V2: A Pilot Study

“…Although such waveforms are part of the physiologic adult ECG morphologic spectrum in V1, their appearance in V2 (or in both V1 and V2) is usually considered abnormal, suggesting ischemia or infarction localized, by common convention, to the interventricular septum (albeit an anatomic oversimplification) (20,(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). Superiorly misplaced right precordial leads also may display altered P-wave morphology (17,20,22,36).…”

“…Yet, despite standardization of their locations since the late 1930s, precordial leads V1 through V6 are still often subject to erroneous and inconsistent placement on the chest (1,(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). Such lapses in procedural adherence can lead not only to altered R-wave amplitude, but also false ECG diagnoses, most significantly ''ischemia'' (T-wave inversion, or ST-segment shifts) and ''infarction'' (Q waves or QS complexes), and additionally, ''Brugada syndrome'' (5,8,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). These misdiagnoses are far from trivial in that they can prolong evaluation time in the emergency department (ED) (and, thereby, contribute to the crowding problem); cause postponement of previously scheduled surgical procedures; lead to unnecessary non-invasive (and perhaps even invasive) diagnostic cardiac tests; prompt treatments that are potentially risky (e.g., intravenous antithrombotic or antiplatelet therapy) or expensive; and possibly raise a red flag if the patient applies for employment or life insurance (22,24).…”

“…Right precordial electrodes V1 and V2-which are supposed to be placed parasternally at the fourth intercostal space (ICS)-are particularly prone to being malpositioned superiorly (i.e., in a cranial direction) on the chest, possibly causing registration of T-wave inversions or QS complexes (6,12,(15)(16)(17)(18)(19)(20)(21)(22). Although such waveforms are part of the physiologic adult ECG morphologic spectrum in V1, their appearance in V2 (or in both V1 and V2) is usually considered abnormal, suggesting ischemia or infarction localized, by common convention, to the interventricular septum (albeit an anatomic oversimplification) (20,(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35).…”