Dual Acute Coronary syndrome Vs. Reciprocal Changes

Very interesting ECG Strip!
1) Poster wall MI 
2) Interior STEMI 
3)reciprocal changes of Inferior MI in lateral Leads
4)complete AV block 

5) Never forget the newer concepts ;
i)ST depression As a reciprocal changes will tell not simply about reciprocating changes as mirror ,It can be “remote Ischemia ” or “ischemia at distance . that is by itself can indicating new current ischemic process other than STEMI localization that must be confirmed by Echocardiography localization of these remote leads representing the other coronary territories . 
ii) In these days there is another new concept that if ST depression in stemi indicating 3 issues : one;reciprocal changes two;Additional IRA ischemia three;ischemia at distance or simultaneous NSTEMI in non IRA . 
this new concept is Dual Acute coronary syndrome ; reciprocal changes defined as ST depression of mirror leads of STEMI leads , but its stressed it’s likely when STEMI is associated with ST depression >5mm in any two leads . when there is disproportionate reciprocal ST depression (>2mm of primary ) . 
so challenge us to give thrombolysis, because thrombolysis is indicated for STEMI and contraindicated for NSTEMI in this case will improve the STEMI related artery patency and worse the NSTEMI related artery , its confirmed by trusted researches . so then immediate PCI is the best initial choice . 
Finally this ECG strip show us another fact that LCx is occluded or RCA ,in 85-90% of case the RCA is dominant but in 10 to 15% of patients the LCx is dominant . so , if we judge through ECG RCA or LCx is occluded , there is one differentiating point that , if ST is elevated more in led III than II there is RCA occluded. this is based on the anatomical anatomical location of the RCA , which circles the Right AV groove and is closer to lead III than II . this is in contrast to lead II is closer to LCx . so , then in this patient , there is RCA occlusion due that confirming the Inferior , Posterior and AV block due to The Bezold–Jarisch reflex that in inferior MI the Vagus is stimulated . and for more ECG diagnosis leads V4R and leads V7,V8 and V9 also be applied to determine the RVMI and Posterior for
more and sure .
written by: Dr.Nabil Paktine