ST-Segment Depression in V₂ With Precordial Hyperacute T-Waves Is an Anterior ST-Segment Elevation Myocardial Infarction (STEMI) Equivalent

Abstract

To the Editor In their report of an inferior and anterior myocardial infarction (MI) owing to an occluded wraparound left anterior descending coronary artery (LAD), Kapil and colleagues 1 attribute the ST depression seen in lead V 2 to a reciprocal change owing to inferior wall involvement by the wraparound vessel. However, whereas leads I and especially aVL will typically manifest reciprocal ST depressions in inferior wall STEMI, this is not the case with lead V 2 unless there is involvement of the posterior wall. Furthermore, the structure of the ST segment in V 2 is not consistent with reciprocal change in this case where there is a broad-based upright T wave that the authors labeled as hyperacute in its form. Thus, rather than reciprocal change, the ST depression in V 2 is more likely an example of an evolving de Winter pattern of hyperacute T waves in acute anterior MI secondary to proximal LAD occlusion. 2 This pattern is characterized by upsloping ST depression and tall symmetric T waves in the precordial leads and is increasingly recognized as a STEMI equivalent requiring urgent revascularization. It is likely that had serial electrocardiograms been performed prior to percutaneous coronary intervention, a full-blown anterior STEMI pattern would have become evident.The authors also note that the algorithm by Fiol and colleagues 3 resulted in misidentification of the right coronary artery as the culprit vessel. However, the algorithm is only intended to predict whether the right coronary artery or left circumflex coronary artery is the culprit vessel for inferoposterior MI. The algorithm would not be appropriate to use when there is substantial electrocardiogram evidence of anterior MI owing to a LAD occlusion.