506
3
Significance of ST Segment Elevations in Posterior Chest Leads (V7 to
V9) in Patients With Acute Inferior Myocardial Infarction: Application
for Thrombolytic Therapy
SHLOMI MATETZKY, MD, DOV FREIMARK, MD, PIERRE CHOURAQUI, MD,
BABETH RABINOWITZ, MD, FACC, SHMUEL RATH, MD, ELIESER KAPLINSKY, MD, FACC,
HANOCH HOD, MD, FACC
Tel-Hashomer and Tel-Aviv, Israel
Objectives. This study was designed to examine whether ST
segment elevation in posterior chest leads (V7 to V9) during acute
inferior myocardial infarction (MI) identifies patients with a
concomitant posterior infarction and whether these patients
might benefit more from thrombolysis.
Background. Because the posterior wall is faced by none of the
12 standard electrocardiographic (ECG) leads, the ECG diagnosis
of posterior infarction is problematic and has often remained
undiagnosed, especially in the acute phase.
Methods. Eighty-seven patients with a first inferior infarction
who were treated with recombinant tissue-type plasminogen acti-
vator were stratified according to the presence (Group A [46
patients]) or absence (Group B [41 patients]) of concomitant ST
segment elevation in posterior chest leads V7 to V9.
Results. Patients in Group A had a higher incidence of postero-
lateral wall motion abnormalities (p < 0.001) on radionuclide
Because none of the 12 standard electrocardiographic (ECG)
leads face the posterior left ventricular wall, the ECG diagnosis
of posterior myocardial infarction (MI) is based on mirror-
image reflection of the electrical events involving the posterior
wall on the precordial leads (1–7). Although an infarction
involving the posterior wall might occur as an isolated infarc-
tion, it occurs more often in association with an inferior
infarction (8). During the acute phase of inferior infarction,
ECG detection of posterior infarction rested on the appear-
ance of concomitant ST segment depression in leads V1 to V3
(2–7). However, these changes are relatively insensitive and
not specific (3,7,9,10) and may represent inferoseptal infarc-
tion (11) or, as suggested earlier by a number of other
investigators (12–16), anterior ischemia or non–Q wave MI.
Because the beneficial effect of thrombolytic therapy is
proportional to the amount of jeopardized myocardium (17–
From the Heart Institute, Sheba Medical Center, Tel-Hashomer; and
Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
Manuscript received July 11, 1997; revised manuscript received October 3,
1997, accepted November 26, 1997.
Address for correspondence: Dr. Hanoch Hod, Heart Institute, Sheba
Medical Center, Tel-Hashomer 52621, Israel. E-mail: babethr@post.tau.ac.il.
©1998 by the American College of Cardiology
Published by Elsevier Science Inc.
JACC Vol. 31, No.
March 1, 1998:506 –11
ventriculography, a larger infarct area (as evidenced by higher
peak creatine kinase levels) (p < 0.02) and a lower left ventricular
ejection fraction (LVEF) at hospital discharge (p < 0.008) than
those in Group B. ST segment elevation in leads V7 to V9 was
associated with a higher incidence of at least one of the following
adverse clinical events: reinfarction, heart failure or death (p 5
0.05). Although patency of the infarct-related artery (IRA) in
Group A resulted in an improved LVEF at discharge (p < 0.012),
LVEF was unchanged in Group B, regardless of the patency status
of the IRA.
Conclusions. ST segment elevation in leads V7 to V9 identifies
patients with a larger inferior MI because of concomitant postero-
lateral involvement. Such patients might benefit more from
thrombolytic therapy.
(J Am Coll Cardiol 1998;31:506 –11)
©1998 by the American College of Cardiology
20), the early appreciation of the extent of an inferior infarc-
tion, and thus the early detection of posterior involvement (8),
is gaining increasing importance in the present era of inter-
ventional therapy. Previous studies have suggested that ECG
recording from the posterior chest leads might directly indicate
the ECG events of the posterior wall (1,21–24), but none of
these studies examined this possibility in the acute phase of
MI. The present study was undertaken 1) to assess the value of
ST segment elevation in posterior chest leads V7 to V9 in the
early diagnosis of posterior wall involvement during the acute
phase of inferior MI; and 2) to test the hypothesis that patients
with an inferior MI in whom this particular ECG pattern is
found might benefit more from thrombolytic therapy than
those in whom this pattern is absent.
Methods
Patients and study protocol. Patients ,75 years old with a
first acute inferior MI in whom thrombolytic therapy could be
initiated within 4 h of symptom onset were eligible for the
study. The diagnosis of inferior MI was based on a history of
chest pain suggestive of myocardial ischemia lasting .30 min
and ECG ST segment elevation $1 mm in at least two of leads
0735-1097/98/$19.00
PII S0735-1097(97)00538-X
JACC Vol. 31, No. 3
March 1, 1998:506 –11
Abbreviations and Acronyms
CK 5 creatine kinase
ECG 5 electrocardiogram, electrocardiographic
IRA 5 infarct-related artery
LVEF 5 left ventricular ejection fraction
MI 5 myocardial infarction
rt-PA 5 recombinant tissue-type plasminogen activator
TIMI 5 Thrombolysis in Myocardial Infarction
II, III and aVF. The diagnosis was confirmed in all patients by
elevation of creatine kinase (CK) levels to at least twice the
higher normal value at our laboratory (#90 IU/liter in men;
#80 IU/liter in women), with the CK, MB fraction .6% of the
highest total CK. CK levels were determined at hospital
admission, every 3 h during the first 24 h and once daily
thereafter. Excluded from the study were patients with an
ECG pattern of complete left bundle branch block or the
accepted contraindications to thrombolysis. The patients were
treated with 100 mg of recombinant tissue-type plasminogen
activator (rt-PA) during 4 h, intravenous infusion of heparin
for at least 5 days and 250 mg of aspirin daily thereafter.
Electrocardiography. A 15-lead ECG was recorded on
hospital admission before initiation of rt-PA and included, in
addition to the standard 12 leads, three posterior chest leads
(V7 to V9). Leads V7 to V9 were recorded in the same
horizontal plane as lead V6 and on the posterior axillary line
(lead V7), the posterior scapular line (lead V8) and the left
border of the spine (lead V9). The ECG was obtained by a
Hewlett-Packard three-channel ECG recorder with flat elec-
trodes, so that the ECG from leads V7 to V9 was recorded
simultaneously using standard electrodes (leads V4 to V6) with
the patient in the supine position. The ECG was reviewed for
the presence of ST segment elevation of at least 0.5 mm in two
or more of leads V7 to V9 and for ST segment depression
$1 mm in two or more of leads V1 to V3. ST segment deviation
was measured 80 ms after the J point. As suggested by previous
studies (22,25), an ST segment elevation of 0.5 mm was
considered significant in the posterior chest leads because of
the greater distance separating the posterior chest wall from
the heart. In addition, the summed ST segment elevations in
the three contiguous leads demonstrating the greatest ST
segment elevation were calculated on the admission ECG. A
$50% decrease in the summed ST segment elevations within
2 h of thrombolytic therapy was considered early ST segment
resolution, as previously proposed by other investigators
(26,27).
Radionuclide ventriculography. To evaluate left ventricu-
lar global and regional function, patients underwent rest gated
blood pool radionuclide imaging within 24 h of hospital
admission, before discharge and 2 months later. Images were
acquired in the anterior and the 45° left anterior oblique (best
septal) projections. Left ventricular ejection fraction (LVEF)
was calculated from the 45° left anterior oblique projection.
For the purpose of evaluation of segmental wall motion, the
MATETZKY ET AL. 507
ST SEGMENT ELEVATION IN LEADS V7 TO V9
left ventricle was divided into five segments: septal, inferoapi-
cal, posterolateral, anterolateral and anterobasal. Regional
wall motion in each segment was graded according to the
following point scale: 1 5 normal; 2 5 mild hypokinesia; 3 5
severe hypokinesia; 4 5 akinesia; and 5 5 dyskinesia.
Angiography. Patients were scheduled to undergo cathe-
terization within 72 h of rt-PA initiation. Significant stenosis in
the large diagonal or marginal branches was considered left
anterior descending or circumflex coronary artery disease,
respectively. The flow pattern of the infarct-related artery
(IRA) was determined by Thrombolysis in Myocardial Infarc-
tion (TIMI) classification criteria. The IRA was considered
patent if perfusion was TIMI grade 2 or 3 and occluded if it was
TIMI grade 0 or 1. In any coronary artery, stenosis was
considered significant if the lumen diameter was narrowed by
$50% in any projection. Using this definition, the number of
significantly diseased coronary vessels was determined. Percu-
taneous transluminal coronary angioplasty of the culprit lesion
was attempted in all patients with significant stenosis or
occlusion of the IRA.
Data analysis. Because the sample size was relatively
small, the study was underpowered to detect differences in
specific clinical outcomes, such as heart failure, reinfarction or
mortality between patients with and without ST segment
elevation in leads V7 to V9. Thus, patients were compared by
means of the prespecified combined clinical end point of heart
failure, reinfarction or death (at least one adverse event).
Results are presented as mean value 6 SD for continuous
variables and as frequency for discrete variables. Continuous
variables were compared by the standard t test, and discrete
variables by chi-square analysis with Yates correction.
Results
Patients. The study group included 87 consecutive patients
with a first inferior MI. No patient was excluded because of
technical problems in recording or reading the ECG from the
posterior leads. Forty-six patients (53%) had significant ST
segment elevation in posterior chest leads V7 to V9 (Group A),
and 41 (47%) did not (Group B). Group A patients had a
significantly higher incidence of previous angina pectoris (39%
vs. 17%, p , 0.02); otherwise, no significant differences were
noted between the two groups with respect to baseline char-
acteristics (Table 1).
Posterolateral involvement and indexes of infarct size.
Group A had a significantly higher incidence of abnormal wall
motion in the posterolateral segment on early ventriculogram
than group B (89% vs. 46%, p , 0.001). When only severe
hypokinesia or more severe wall motion abnormality was
considered, the differences were even more pronounced (87%
in Group A vs. 24% in Group B, p , 0.001). In other respects,
the distribution of the regional wall motion abnormalities was
comparable between the two groups. Patients with ST segment
elevation in the posterior leads had a significantly lower LVEF
than those without this ECG pattern at hospital discharge
(53 6 14 vs. 60 6 9, p , 0.008) and 2 months later (55 6 10 vs.
508 MATETZKY ET AL. JACC Vol. 31, No. 3
ST SEGMENT ELEVATION IN LEADS V7 TO V9 March 1, 1998:506 –11

Table 1. Baseline Characteristics Table 3. In-Hospital Clinical Course

Group A Group B p Group A Group B
(n 5 46) (n 5 41) Value (n 5 46) (n 5 41)
Age (yr) 57 6 10 54 6 10 0.17 Reinfarction 10 (22%) 4 (10%)
Female gender 10 (22%) 5 (12%) 0.24 Postinfarction angina 2 (4.5%) 2 (5%)
Previous angina 18 (39%) 7 (17%) 0.02 High degree AV block 2 (4.5%) 7 (17%)
Risk factors for CAD CHF 5 (11%) 2 (5%)
Smoking 36 (78%) 31 (76%) 0.77 CABG 1 (2%) 1 (2.5%)
Hyperlipidemia 15 (33%) 12 (29%) 0.74 Mortality 3 (6.5%) 1 (2.5%)
Hypertension 9 (20%) 6 (15%) 0.54 Combined adverse clinical event 12 (26%)* 4 (10%)*
Diabetes mellitus 5 (11%) 5 (12%) 0.85 (CHF, reinfarction, death)
Interval from onset of 134 6 39 124 6 48 0.29
*p 5 0.05, Group A versus Group B. Data presented are number (%) of
symptoms to initiation
patients. AV 5 atrioventricular; CABG 5 coronary artery bypass graft surgery;
of rt-PA (min)
CHF 5 congestive heart failure; other abbreviations as in Table 1.
PTCA 25 (54%) 21 (51%) 0.77
Data presented are mean value 6 SD or number (%) of patients. CAD 5
coronary artery disease; Group A 5 patients with ST segment elevation in leads Clinical findings (Table 3). The patients with concomitant
V7 to V9; Group B 5 patients without ST segment elevation in leads V7 to V9; ST segment elevation in leads V7 to V9 (Group A) appeared to
PTCA 5 percutaneous transluminal coronary angioplasty; rt-PA 5 recombinant have a more complicated in-hospital course than those in
tissue-type plasminogen activator.
group B, as manifested by higher occurrence rate of the
combined clinical end point of at least one of the following
60 6 10, p , 0.02). In accordance, group A had significantly adverse clinical events: reinfarction, heart failure or death
higher peak CK levels than those without these changes (26% vs. 10%, p # 0.05).
(1,254 6 673 vs. 847 6 723 IU/liter, p , 0.05). Comparison of ST segment elevation in leads V7 to V9 and
Angiography. The IRA could be identified in 85 patients ST segment depression in leads V1 to V3. Significant ST
(98%). In two patients (one in group A and one in group B), segment depression in leads V1 to V3 was noted in 52 patients
no significant stenosis was seen. The left circumflex coronary (60%). The occurrence of ST segment depression in the
artery was the IRA in a significantly higher proportion of precordial leads agreed only partially with the occurrence of
patients in group A than group B (35% vs. 5%, p , 0.001). The ST segment elevation in the posterior chest leads. In 10 Group
reverse was noted with respect to the right coronary artery, A patients (22%), ST segment depression was not present on
which was the IRA in 63% of patients presenting with ST the admission ECG, and 16 patients (31%) with ST segment
segment elevation in the posterior lead and in 90% of those depression in leads V1 to V3 had no ST segment elevation in
without this ECG pattern (p , 0.003). leads V7 to V9 (Fig. 1).
Despite the differences in the identity of the culprit vessel, When ST segment elevation in leads V7 to V9 and ST
both groups had a similar patency rate and a similar incidence segment depression in leads V1 to V3 at hospital admission
of multivessel coronary artery disease (Table 2). Among the 65 were compared with respect to diagnostic accuracy of posterior
patients with a patent IRA in both groups, early ST segment involvement (at least severe hypokinesia), ST segment eleva-
elevation resolution and early (within 12 h) peak CK were tion in leads V7 to V9 had a similar sensitivity (80% vs. 72%,
noted in 55 patients (82%). In comparison, the two aforemen- p 5 0.34) but a higher specificity (84% vs. 57%, p 5 0.02) and
tioned clinical signs of reperfusion were noted in only three test accuracy (82% vs. 66%, p 5 0.01).
patients (15%) from among those with an occluded IRA (p , Beneficial effect of an open IRA in patients with an inferior
0.01). MI with and without posterior lead ST segment elevation. To
assess the impact of thrombolytic therapy, LVEF was analyzed
Table 2. Angiographic Findings in both groups according to IRA patency (Fig. 2). In patients
Group A Group B p with ST segment elevation in leads V7 to V9 (Group A), IRA
(n 5 46) (n 5 41) Value patency resulted in a higher LVEF both at hospital discharge
Time to cath (days) 4.3 6 1.7 4.3 6 1.8 1.0 (56 6 13 vs. 44 6 12, p , 0.012) and at the 2-month follow-up
IRA visit (56 6 10 vs. 49 6 9, p 5 0.052). In patients without
RCA 29 (63%) 37 (90%) 0.003 posterior ST segment elevation, LVEF was similar with or
LCx 16 (35%) 2 (5%) 0.001 without IRA patency at hospital discharge (59 6 10 vs. 61 6 9
LAD 0 1 (2.5%) 0.95
[p 5 0.4]) and at the 2-month follow-up visit (60 6 9.5 vs. 59 6
Undetermined 1 (2%) 1 (2.5%) 1.0
Patent IRA 36 (78%) 31 (76%) 0.77 13 [p 5 0.7]).
Multivessel CAD 21 (46%) 17 (41%) 0.68
Data presented are mean value 6 SD or number (%) of patients. cath 5 Discussion
catheterization; IRA 5 infarct-related artery; LAD 5 left anterior descending
coronary artery; LCx 5 left circumflex coronary artery; RCA 5 right coronary Classically, ECG diagnosis of posterior wall infarction is
artery; other abbreviations as in Table 1. based on the appearance of prominent R waves in leads V1 and
JACC Vol. 31, No. 3
March 1, 1998:506 –11
Figure 1. ECGs from two patients with an inferior MI judged to have
significant ST segment elevation in leads V7 to V9 with (left panel) and
without concomitant ST segment depression in leads V1 to V3 (right
panel).
V2, but these R waves might appear hours after the onset of
symptoms. Previous investigators (2–7) have suggested that
precordial ST segment depression during the acute stage of
inferior MI might be related to posterior wall involvement.
However, such precordial ST segment depression might also
reflect anterior wall ischemia or non–Q wave MI (12–16).
Furthermore, precordial ST segment depression might be
diminished by right ventricular infarction (25) or might be
masked by the development of a complete right bundle branch
block pattern. Consequently, this ECG sign has low to mod-
erate sensitivity and specificity for posterior wall infarction
(3,4,7,9 –12).
MATETZKY ET AL. 509
ST SEGMENT ELEVATION IN LEADS V7 TO V9
Figure 2. Flowchart illustrating distribution of patients (PTS) with and
without ST segment elevation (ST 1) in leads V7 to V9 at hospital
admission according to IRA patency and LVEF in each of the four
groups that resulted.
Previous studies (1,21,22) have demonstrated the appear-
ance of pathologic Q waves in posterior chest leads in patients
with an old posterior infarction. However, these studies in-
cluded only a small number of patients in whom posterior
infarction was diagnosed by standard ECG (21,22) or vector-
cardiographic criteria (1). Rich et al. (23) studied 369 patients
who underwent exercise testing with thallium scintigraphy, 27
of whom met scintigraphic criteria for posterior infarction.
They showed that the presence of Q waves in lead V9 was more
accurate than the classic standard ECG criteria for diagnosing
posterior infarction. In accordance with our results, Zalenski et
al. (24) found ST segment elevation in leads V7 to V9 in 6
(50%) of 12 patients with an acute inferior MI. However, the
presence of a posterior infarction in patients with ST segment
elevation in leads V7 to V9 was not confirmed, and patients
with and without ST segment elevation were not compared.
We showed that the early diagnosis of concomitant postero-
lateral infarction in patients with an acute inferior MI could be
made on the basis of the presence of ST segment elevation in
leads V7 to V9 and that these ECG changes are more accurate
than ST segment depression in precordial leads for detecting
posterior involvement. Consequently, concomitant ST segment
elevation in leads V7 to V9 identified a subset of patients with
a larger inferior MI, as evidenced by higher peak CK levels and
poorer left ventricular function. The higher incidence of a
combined clinical end point (heart failure, reinfarction or
mortality) in patients with ST segment elevation in leads V7 to
V9 suggests that these patients might also have had a more
complicated clinical course.
Our results with regard to the differences in the identity of
the IRA among patients with and without ST segment eleva-
tion in leads V7 to V9 concur with those of previous studies
(28 –30) showing that posterior wall infarction was associated
with more frequent circumflex artery disease. Complete atrio-
ventricular block is almost entirely restricted to right coronary
artery–related infarction (31), thus possibly also explaining the
somewhat higher incidence of high degree atrioventricular
block in Group B than in Group A patients.
510 MATETZKY ET AL.
ST SEGMENT ELEVATION IN LEADS V7 TO V9
Beneficial effect of thrombolytic therapy in inferior wall
infarction with and without ST segment elevation in leads V7
to V9. Previous studies that evaluated the results of thrombo-
lytic therapy for inferior MI demonstrated only an insignificant
trend toward mortality reduction (17–20) and yielded conflict-
ing conclusions with respect to the resulting improvement in
left ventricular function (32–36). Nevertheless, only few studies
have evaluated the beneficial effect of thrombolytic therapy in
high risk subsets of patients with an inferior MI. Bar et al. (37)
demonstrated a higher, enzymatically estimated infarct size
limitation after successful thrombolysis in patients with an
inferior MI with a summed ST segment elevation .6 mm than
in those with a lower summed ST segment elevation. However,
they did not extrapolate their results to terms of ventricular
function. Berland et al. (38) found postreperfusion improve-
ment in segmental contraction only in patients who had
concomitant precordial lead ST segment depression on the
admission ECG, but they failed to show similar differences
regarding LVEF. However, Bates et al. (36) postulated an
insignificant improvement in either regional or global left
ventricular function in patients with an inferior MI after
thrombolytic therapy, with or without ST segment depression
in leads V1 to V4.
In the present study, a patent IRA appeared to be more
beneficial in patients with an inferior MI with ST segment
elevation in posterior leads V7 to V9 at hospital admission.
Previous studies (39,40) have shown that the amount of
myocardial salvage by thrombolytic therapy is proportional to
the initial amount of jeopardized myocardium. Thus, the
concomitant posterolateral involvement in patients with ST
segment elevation in leads V7 to V9 on hospital admission,
which indicates a larger infarct, presumably accounts for the
higher beneficial effect in these patients.
Moreover, in patients with an inferior infarction, posterior
involvement is associated with the development of significant
mitral regurgitation, although successful thrombolysis reduces
the prevalence of mitral regurgitation in conjunction with a
reduction in the prevalence of posterior wall motion abnor-
malities (41).
Study limitations. The present study is limited by its small
sample size and is therefore underpowered to detect differ-
ences in specific clinical outcomes and the beneficial effects of
thrombolysis in terms of clinical results between Groups A and
B. We therefore suggest that the present study, which reports
initial results, should be interpreted with caution. Larger
studies are needed.
The patients in the present study underwent catheterization
on the fourth day, on average; thus, only the impact of
“patency” and not “early reperfusion” could be determined.
Yet the similar timing of catheterization and the similar
incidence of early reinfarction (within 72 h) in both groups, as
well as the much higher occurrence of clinical signs of reper-
fusion in patients with a patent IRA, suggest that the inter-
group differences in left ventricular function response to
patency reflect differences in the beneficial effects of throm-
bolysis.
JACC Vol. 31, No. 3
March 1, 1998:506 –11
Conclusions. We recommend routine recording of leads
V7 to V9 in all patients admitted to the hospital with an acute
inferior MI and suggest that ST segment elevation in these
leads, because it implies a large area of jeopardized myocar-
dium, might argue in favor of thrombolytic therapy or another
form of reperfusion, such as direct coronary angioplasty.
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