Improved detection of posterior myocardial wall ischemia with the 15-lead electrocardiogram,

Background: A routine 12-lead electrocardiogram is commonly obtained to evaluate for possible acute myocardial infarction during the initial screening of patients with chest discomfort. Posterior myocardial infarction is commonly missed because it is not usually visible in the standard leads. In this study, we compared the sensitivity and specificity of posterior chest leads (V7, V8, and V9) and 12-lead electrocardiography in detecting posterior injury pattern during single-vessel percutaneous transluminal coronary angioplasty. Methods and Results: Three posterior chest leads in addition to the routine 12-lead electrocardiogram were monitored simultaneously during single-vessel percutaneous transluminal coronary angioplasty of the right, circumflex, and left anterior descending coronary arteries in a total of 223 patients. Posterior injury patterns (95%) were detected mostly during circumflex coronary occlusion. Posterior leads were able to detect injury pattern in 49% (36 of 74) of patients, whereas the 12-lead electrocardiogram was able to detect only 32% (P < .04). When all 15 leads were used to detect all ST elevations, sensitivity increased to 57%, with a specificity of 98% for the circumflex coronary artery. If maximal ST depressions in leads V2 to V3 are considered to be from posterior myocardial injury, then the overall sensitivity is increased to 69%. Conclusions: Posterior leads significantly increased the detection of posterior injury pattern compared with the standard 12-lead electrocardiogram. Using all 15 leads significantly further improved the detection of circumflex coronary–related injury pattern over the standard 12-lead electrocardiogram. (Am Heart J 1999;138:934-40.)