Posterior Wall Myocardial Infarction (MI) ECG Review

The ECG findings of a posterior wall myocardial infarction are different than the typical ST segment elevation seen in other myocardial infarctions.

A posterior wall MI occurs when posterior myocardial tissue (now termed inferobasilar), usually supplied by the posterior descending artery a branch of the right coronary artery in 80% of individuals  acutely loses blood supply due to intracoronary thrombosis in that vessel. This frequently coincides with an inferior wall MI due to the shared blood supply.

The ECG findings of an acute posterior wall MI include the following:

  1. ST segment depression (not elevation) in the septal and anterior precordial leads (V1-V4). This occurs because these ECG leads will see the MI backwards; the leads are placed anteriorly, but the myocardial injury is posterior.
  2. A R/S wave ratio greater than 1 in leads V1 or V2.
  3. ST elevation in the posterior leads of a posterior ECG (leads V7-V9). Suspicion for a posterior MI must remain high, especially if inferior ST segment elevation is also present.
  4. ST segment elevation in the inferior leads (II, III and aVF) if an inferior MI is also present.

ECG Examples:

1. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
2. Surawicz B, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Circulation. 2009; doi:10.1161/CIRCULATIONAHA.108.191095.