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Anterior STEMI (Localization of LAD Occlusion)

Anterior STEMI myocardial infarction and localisation occlusion (culprit artery) of the left anterior descending artery (LAD)

Vascular Supply of the Anterior Wall

  • The anterior wall is supplied by the LAD:
  • S1 (First Septal Branch)
  • D1 (First Diagonal Branch)
    • It is the second most proximal branch of the LAD
    • Supplies the lateral part of the left ventricle
    • Corresponds with the leads (I, aVL)
  • Leads observing the anterior wall:
  • Basic vascular supply of the heart:
    • RCA (Right Coronary Artery)
    • LCA (Left Coronary Artery)
    • LAD (Left Anterior Descending Artery)
    • LCx (Left Circumflex Artery)
    • PDA (Posterior Descending Artery)
Anterior STEMI, sites of occlusion LAD (left anterior descending artery), S1 (first septal branch), D1 (first diagonal branch)

Anterior Wall STEMI

Anterior wall myocardial infarction, LAD occlusion proximal to both S1 and D1

Reciprocal Changes and Antero-lateral STEMI

Anterior STEMI, ST elevation, reciprocal ST depression
  • In STEMI infarction, ST elevations occur
  • Reciprocal changes (ST depressions) occur in STEMI
    • in the leads that are opposite to the ST elevations
  • Anterior STEMI (ST elevations V1-V4)
    • Does not create reciprocal changes
    • because there are no leads opposite to leads V1-V4
  • Reciprocal changes are seen in antero-lateral STEMI
    • The high lateral area must be affected
    • because the leads opposite to (aVL, I) are (III, aVF)

  • NSTEMI infarction never creates reciprocal changes

Dynamics of ST Elevations in STEMI

Anterior STEMI ST elevation evolution, acute, subacute, postacute, chronic, old infarction

Classification of STEMI by Stage


ECG and Anterior STEMI

  • Acute STEMI is localized according to ST elevations
  • Size of ST elevations in STEMI
    • Men ≥ 40 years:
      • ≥ 2mm (V2-V3)
      • ≥ 1mm in other leads
    • Men < 40 years:
      • ≥ 2.5mm (V2-V3)
      • ≥ 1mm in other leads
    • Women (regardless of age)
      • ≥ 1.5mm (V2-V3)
      • ≥ 1mm in other leads
Anterior STEMI ECG diagnosis criteria

LAD Occlusion with "Wraparound"

Wraparound LAD, Extending LAD beyond cardiac apex and wrapping around, Anterior STEMI, Inferior STEMI

Classification of Anterior STEMI

  • The more proximal the LAD occlusion, the larger the infarction
  • ST elevations occur in the leads that "look" at the infarction
  • Based on the ST elevations, the following can be localized:
    • Infarction zone
    • LAD occlusion

STEMI ST elevations Reciprocal ST depressions
Septal V1-V2 None
Anterior V2-V5 None
Anteroseptal V1-V4 None
Anterolateral V3-V6, I, aVL III, aVF
Extensive Anterior V1-V6, I, aVL III, aVF
Anteroinferior
(Wraparound LAD)		 (V2-V4) + (II, III, aVF) None

Localization of Occlusion in the LAD

anatomy localisation left anterior descending artery (LAD)

ECG and Occlusion of the LAD Proximal to S1, D1

Anterior STEMI, LAD occlusion proximal to S1 D1, electrical vector, ST elevation, ST depression
  • Ischemia affects
    • Anterior wall
    • Lateral wall
    • 2/3 of the septum
  • Ischemic vector points
    • Between leads (aVR, aVL)
    • Away from the inferior leads (II, III, aVF)

  • ECG and Occlusion of the LAD Proximal to S1, D1
    • ST elevations (V1-V4, I, aVL, aVR)
      • V1 > 2mm
      • aVL > aVR
      • V2 > V3 > V1
    • Reciprocal ST depressions (II, III, aVF)
      • Depression in III > II
      • Depression V6 > V5
    • Right Bundle Branch Block
      • Occurs almost always

  • Wellens' Syndrome is
    • Proximal stenosis of the LAD
  • Windowmaker artery is
    • Proximal stenosis or occlusion of the LAD

ECG and Occlusion of the LAD Between S1 and D1

Anterior STEMI, LAD occlusion between S1 and D1 (distal to first septal branch, proximal to first diagonal branch), electrical vector, ST elevation, ST depression

ECG and Occlusion of the LAD Between D1 and S1

Anterior STEMI, LAD occlusion between D1 and S1 (distal to first diagonal branch, proximal to first septal branch), electrical vector, ST elevation, ST depression
  • This is a variant of the LAD, where D1 is the first branch and S1 is the second
  • The occlusion is
    • Distal to D1
    • Proximal to S1
  • Ischemia affects
    • Anterior wall
    • 2/3 of the septum
  • Ischemic vector points
    • Towards leads (II, III, aVF)
    • Away from leads (I, aVL)


  • ECG and Occlusion of the LAD Between D1 and S1
    • ST elevations (V1-V4, II, III, aVF)
      • III > II
      • Also in V1
    • Reciprocal ST depressions
      • I, aVL

ECG and Occlusion of the LAD Distal to S1, D1

LAD (RIA) occlusion distal to both the first septal branch (S1) and the first diagonal branch (D1), and electrical ischemic vector

Left anterior descending artery (LAD) occlusion proximal to S1 and D1
ECG acute anterior STEMI myocardial infarction, left anterior hemiblock, LAD occlusion proximal to first septal (S1) and first diagonal branches (D1)

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V1-V4, I, aVL, aVR)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates proximal occlusion of the LAD (Left Anterior Descending artery) from S1 and D1
    • ST Elevations (V1-V4, I, aVL, aVR)
      • V1 > 2mm
      • aVL > aVR
    • Reciprocal ST Depressions (II, III, aVF)
      • Depression in III > II
  • Left Anterior Hemiblock


old antero-septal myocardial infarction
ECG old anterior myocardial infarction, pathologic Q wave V1-V3, acute ischemia - giant negative T waves V2-V5

Old Anterior Myocardial Infarction



Left anterior descending artery (LAD) occlusion proximal to S1 and D1
ECG acute extensive anterior STEMI infarction, proximal left anterior descending artery (LAD), proximal to D1, S1

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V1-V4, I, aVL, aVR)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates occlusion of the LAD proximal to S1 and D1
    • ST Elevations (V1-V4, I, aVL, aVR)
      • V1 > 2mm
      • aVL > aVR
    • Reciprocal ST Depressions (II, III, aVF)
      • Depression in III > II
  • Left Anterior Hemiblock


Distal LAD occlusion of first septal branch (S1), distal of first diagonal branch (D1)
ECG acute anterior STEMI infarction, occlusion distal LAD, ST elevation V3-V6

Acute Anterior STEMI



LAD occlusion proximal from 1st diagonal branch, and distal from 1st septal perforator branch
ECG anterior STEMI infarction, ST elevation (V2-V5, I, aVL), reciprocal ST depression (II, III, aVL), culprit artery - vessel: LAD between S1 and D1

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V2-V5, I, aVL)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates occlusion of the LAD between S1 and D1
    • ST Elevations (V2-V4, I, aVL)
    • ST Depressions (II, III, aVF)
      • Depression in III > II


LAD occlusion proximal from 1st diagonal branch, and distal from 1st septal perforator branch
ECG acute LAD occlusion proximal to first diagonal branch, Acute antero-lateral STEMI infarction

Acute Anterior STEMI



occlusion wrap-around artery, anterior and inferior STEMI infarction
ECG anterior and infero-apical STEMI, massive ST elevation, occlusion wraparound artery

Acute Anterior and Inferior STEMI

  • Sinus Rhythm
  • Inferior STEMI
    • ST Elevations (II, III, aVF)
  • Anterior STEMI
    • ST Elevations (V1-V5)
  • Anterior and inferior STEMI is very rare
    • The patient had a LAD occlusion with a wraparound artery
    • The distal LAD wraps around the apex and continues as the RIP


anterior STEMI infarction and RBBB
ECG acute anterior STEMI infarction and right bundle branch block (RBBB)

Acute Anterior STEMI




Sources

  • ECG from Basics to Essentials Step by Step
  • litfl.com
  • ecgwaves.com
  • metealpaslan.com
  • medmastery.com
  • uptodate.com
  • ecgpedia.org
  • wikipedia.org
  • Strong Medicine
  • Understanding Pacemakers





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Home /

Anterior STEMI (Localization of LAD Occlusion)

Anterior STEMI myocardial infarction and localisation occlusion (culprit artery) of the left anterior descending artery (LAD)

Vascular Supply of the Anterior Wall

  • The anterior wall is supplied by the LAD:
  • S1 (First Septal Branch)
  • D1 (First Diagonal Branch)
    • It is the second most proximal branch of the LAD
    • Supplies the lateral part of the left ventricle
    • Corresponds with the leads (I, aVL)
  • Leads observing the anterior wall:
  • Basic vascular supply of the heart:
    • RCA (Right Coronary Artery)
    • LCA (Left Coronary Artery)
    • LAD (Left Anterior Descending Artery)
    • LCx (Left Circumflex Artery)
    • PDA (Posterior Descending Artery)
 Anterior STEMI, sites of occlusion LAD (left anterior descending artery), S1 (first septal branch), D1 (first diagonal branch)

Anterior Wall STEMI

  • Occurs due to occlusion of the LAD
    • The more proximal the occlusion, the larger the infarction
  • Has the worst prognosis of all infarctions
  • Based on ST elevations and reciprocal changes, it can be localized:
    • Occlusion in the LAD
    • Necrotic area in the anterior wall
  • Only STEMI infarction can be localized
    • NSTEMI cannot be localized by ECG
 Anterior wall myocardial infarction, LAD occlusion proximal to both S1 and D1

Reciprocal Changes and Antero-lateral STEMI

  • In STEMI infarction, ST elevations occur
  • Reciprocal changes (ST depressions) occur in STEMI
    • in the leads that are opposite to the ST elevations
  • Anterior STEMI (ST elevations V1-V4)
    • Does not create reciprocal changes
    • because there are no leads opposite to leads V1-V4
  • Reciprocal changes are seen in antero-lateral STEMI
    • The high lateral area must be affected
    • because the leads opposite to (aVL, I) are (III, aVF)

  • NSTEMI infarction never creates reciprocal changes
 Anterior STEMI, ST elevation, reciprocal ST depression

Dynamics of ST Elevations in STEMI

Anterior STEMI ST elevation evolution, acute, subacute, postacute, chronic, old infarction

Classification of STEMI by Stage


ECG and Anterior STEMI

  • Acute STEMI is localized according to ST elevations
  • Size of ST elevations in STEMI
    • Men ≥ 40 years:
      • ≥ 2mm (V2-V3)
      • ≥ 1mm in other leads
    • Men < 40 years:
      • ≥ 2.5mm (V2-V3)
      • ≥ 1mm in other leads
    • Women (regardless of age)
      • ≥ 1.5mm (V2-V3)
      • ≥ 1mm in other leads
Anterior STEMI ECG diagnosis criteria

LAD Occlusion with "Wraparound"

  • Apex "Wraparound"
    • Occurs in 0.1% of people
    • LAD wraps around the apex of the heart and continues as the PDA on the inferior wall
  • In case of LAD occlusion with wraparound, an infarction occurs:
    • Anterior wall (ST elevations V2-V4)
    • Inferior wall (ST elevations II, III, aVF)
  • This is a very rare situation
  • ST elevations will not be significant
    • because the leads of the anterior and inferior walls are partially contralateral
    • Vectors of the anterior and inferior walls point partially away from each other
 Wraparound LAD, Extending LAD beyond cardiac apex and wrapping around, Anterior STEMI, Inferior STEMI

Classification of Anterior STEMI

  • The more proximal the LAD occlusion, the larger the infarction
  • ST elevations occur in the leads that "look" at the infarction
  • Based on the ST elevations, the following can be localized:
    • Infarction zone
    • LAD occlusion

STEMI ST elevations Reciprocal ST depressions
Septal V1-V2 None
Anterior V2-V5 None
Anteroseptal V1-V4 None
Anterolateral V3-V6, I, aVL III, aVF
Extensive Anterior V1-V6, I, aVL III, aVF
Anteroinferior
(Wraparound LAD)		 (V2-V4) + (II, III, aVF) None

Localization of Occlusion in the LAD

  • S1 (First Septal Branch)
  • D1 (First Diagonal Branch)
    • It is the second most proximal branch of the LAD
    • Supplies the lateral part of the left ventricle
    • Corresponds to the leads (I, aVL)
    • Occlusion of the LAD proximal to D1 shows on the ECG:
      • ST elevations (aVL, I)
      • ST depressions (III, II)

  • Occlusion (Culprit artery) of the LAD can be:
    • Proximal to S1, D1
    • Between S1 and D1
    • Between D1 and S1 (D1 branches off first, then S1)
    • Distal to S1, D1

anatomy localisation left anterior descending artery (LAD)

ECG and Occlusion of the LAD Proximal to S1, D1

  • Ischemia affects
    • Anterior wall
    • Lateral wall
    • 2/3 of the septum
  • Ischemic vector points
    • Between leads (aVR, aVL)
    • Away from the inferior leads (II, III, aVF)

  • ECG and Occlusion of the LAD Proximal to S1, D1
    • ST elevations (V1-V4, I, aVL, aVR)
      • V1 > 2mm
      • aVL > aVR
      • V2 > V3 > V1
    • Reciprocal ST depressions (II, III, aVF)
      • Depression in III > II
      • Depression V6 > V5
    • Right Bundle Branch Block
      • Occurs almost always

  • Wellens' Syndrome is
    • Proximal stenosis of the LAD
  • Windowmaker artery is
    • Proximal stenosis or occlusion of the LAD
 Anterior STEMI, LAD occlusion proximal to S1 D1, electrical vector, ST elevation, ST depression

ECG and Occlusion of the LAD Between S1 and D1

  • The occlusion is
    • Distal to S1
    • Proximal to D1
  • Ischemia affects
    • Anterior wall
    • Lateral wall
  • Ischemic vector points
    • Towards leads (I, aVL)
    • Away from leads (III, aVF)



  • ECG and Occlusion of the LAD Between S1 and D1
    • ST elevations (V2-V4, I, aVL)
      • Not in V1, aVR
    • Reciprocal ST depressions (II, III, aVF)
      • Depression in III > II
Anterior STEMI, LAD occlusion between S1 and D1 (distal to first septal branch, proximal to first diagonal branch), electrical vector, ST elevation, ST depression

ECG and Occlusion of the LAD Between D1 and S1

  • This is a variant of the LAD, where D1 is the first branch and S1 is the second
  • The occlusion is
    • Distal to D1
    • Proximal to S1
  • Ischemia affects
    • Anterior wall
    • 2/3 of the septum
  • Ischemic vector points
    • Towards leads (II, III, aVF)
    • Away from leads (I, aVL)


  • ECG and Occlusion of the LAD Between D1 and S1
    • ST elevations (V1-V4, II, III, aVF)
      • III > II
      • Also in V1
    • Reciprocal ST depressions
      • I, aVL
Anterior STEMI, LAD occlusion between D1 and S1 (distal to first diagonal branch, proximal to first septal branch), electrical vector, ST elevation, ST depression

ECG and Occlusion of the LAD Distal to S1, D1

  • Ischemia affects
    • Anterior wall
    • Apex
  • Ischemic vector points
    • Towards leads (V3-V6, aVF, II)
    • Away from lead (aVR)



  • ECG and Occlusion of the LAD Distal to S1, D1
    • ST elevations (V3-V6)
      • May also be seen in (II, III, aVF)
        • If present, ST elevation in II > III
      • Not in (V1, aVR)
    • Reciprocal ST depression (aVR)
LAD (RIA) occlusion distal to both the first septal branch (S1) and the first diagonal branch (D1), and electrical ischemic vector


ECG acute anterior STEMI myocardial infarction, left anterior hemiblock, LAD occlusion proximal to first septal (S1) and first diagonal branches (D1)

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V1-V4, I, aVL, aVR)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates proximal occlusion of the LAD (Left Anterior Descending artery) from S1 and D1
    • ST Elevations (V1-V4, I, aVL, aVR)
      • V1 > 2mm
      • aVL > aVR
    • Reciprocal ST Depressions (II, III, aVF)
      • Depression in III > II
  • Left Anterior Hemiblock
 Left anterior descending artery (LAD) occlusion proximal to S1 and D1


ECG old anterior myocardial infarction, pathologic Q wave V1-V3, acute ischemia - giant negative T waves V2-V5

Old Anterior Myocardial Infarction

 old antero-septal myocardial infarction


ECG acute extensive anterior STEMI infarction, proximal left anterior descending artery (LAD), proximal to D1, S1

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V1-V4, I, aVL, aVR)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates occlusion of the LAD proximal to S1 and D1
    • ST Elevations (V1-V4, I, aVL, aVR)
      • V1 > 2mm
      • aVL > aVR
    • Reciprocal ST Depressions (II, III, aVF)
      • Depression in III > II
  • Left Anterior Hemiblock
 Left anterior descending artery (LAD) occlusion proximal to S1 and D1


ECG acute anterior STEMI infarction, occlusion distal LAD, ST elevation V3-V6

Acute Anterior STEMI

 Distal LAD occlusion of first septal branch (S1), distal of first diagonal branch (D1)


ECG anterior STEMI infarction, ST elevation (V2-V5, I, aVL), reciprocal ST depression (II, III, aVL), culprit artery - vessel: LAD between S1 and D1

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V2-V5, I, aVL)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates occlusion of the LAD between S1 and D1
    • ST Elevations (V2-V4, I, aVL)
    • ST Depressions (II, III, aVF)
      • Depression in III > II
 LAD occlusion proximal from 1st diagonal branch, and distal from 1st septal perforator branch


ECG acute LAD occlusion proximal to first diagonal branch, Acute antero-lateral STEMI infarction

Acute Anterior STEMI

  • Sinus Rhythm
  • ST Elevations (V2-V6, I, aVL)
  • Reciprocal ST Depressions (II, III, aVF)
  • Indicates occlusion of the LAD between S1 and D1
    • ST Elevations (V2-V6, I, aVL)
    • ST Depressions (II, III, aVF)
      • Depression in III > II
 LAD occlusion proximal from 1st diagonal branch, and distal from 1st septal perforator branch


ECG anterior and infero-apical STEMI, massive ST elevation, occlusion wraparound artery

Acute Anterior and Inferior STEMI

  • Sinus Rhythm
  • Inferior STEMI
    • ST Elevations (II, III, aVF)
  • Anterior STEMI
    • ST Elevations (V1-V5)
  • Anterior and inferior STEMI is very rare
    • The patient had a LAD occlusion with a wraparound artery
    • The distal LAD wraps around the apex and continues as the RIP
 occlusion wrap-around artery, anterior and inferior STEMI infarction


ECG acute anterior STEMI infarction and right bundle branch block (RBBB)

Acute Anterior STEMI

 anterior STEMI infarction and RBBB



Sources

  • ECG from Basics to Essentials Step by Step
  • litfl.com
  • ecgwaves.com
  • metealpaslan.com
  • medmastery.com
  • uptodate.com
  • ecgpedia.org
  • wikipedia.org
  • Strong Medicine
  • Understanding Pacemakers