ECG Exercise 33 - Acute Myocardial Infarction

Last updated 11/9/26

Below is an ECG Exercise focused on acute myocardial infarction (part of the Self-Study Curriculum). ECGs are from Garcia, 12-Lead ECG: The Art of Interpretation, Chapter 15.

STEMI Criteria, Regions, and Reciprocal Changes

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What are the ECG criteria for STEMI?

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Which leads represent each region of the heart?

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What are reciprocal changes, and which leads can truly be reciprocal?

Anteroseptal AMI

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Which leads are involved in an anteroseptal AMI? Does it cause reciprocal changes in the limb leads?

ECG 1

[Insert image - Garcia ECG 15-1]

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What is the rate, rhythm, and axis?

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Which leads show ST elevation? What is the diagnosis?

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Look closely at aVL and the inferior leads. What do you see?

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There is also ST depression in I and V6. Is it reciprocal to the anteroseptal infarct?

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ECG ____

ECG 2

[Insert image - Garcia ECG 15-2]

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What is the rate, rhythm, and axis?

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Describe the ST segments in V1-V3. What territory is affected?

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Describe the T waves in V2-V4. Why do they matter?

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Which leads are developing Q waves, and what does that say about timing?

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ECG ____

ECG 3

[Insert image - Garcia ECG 15-3]

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What is the rate, rhythm, and axis?

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Where is the ST elevation, and where are the pathologic Q waves?

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The inferior complexes are mostly negative. Is there also an old inferior MI?

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Describe the T waves in V5-V6. What do they mean?

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Assess the R wave progression. What does it suggest?

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What other findings are present?

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ECG ____

Anteroseptal AMI with Lateral Extension

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Which leads are involved, and what is the culprit artery?

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What are hyperacute changes, and why do they matter?

ECG 4

[Insert image - Garcia ECG 15-4]

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What is the rate, rhythm, and axis?

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Which leads show ST elevation? What is the diagnosis?

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Where are the reciprocal changes?

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Which leads are forming Q waves?

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Look at the size of the ST segments and T waves. What does this say about timing?

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ECG ____

ECG 5

[Insert image - Garcia ECG 15-5]

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What is the rate, rhythm, and axis?

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Which leads show ST changes? What is the diagnosis?

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The ST segment in V2 looks hyperacute. What does it suggest about the stage of the AMI?

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Where are the reciprocal changes?

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ECG ____

ECG 6

[Insert image - Garcia ECG 15-6]

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What is the rate, rhythm, and axis?

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Which leads show ST changes? What is the diagnosis?

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Where are the QS waves? Is V1 a QS complex?

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Which other leads show Q waves?

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ECG ____

ECG 7

[Insert image - Garcia ECG 15-7]

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What is the rate, rhythm, and axis?

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Which leads show ST elevation? What is the diagnosis?

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Where are the reciprocal changes?

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Don't stop at the AMI. What else is on this ECG?

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ECG ____

ECG 8

[Insert image - Garcia ECG 15-8]

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What is the rate and axis?

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Look at the P waves in II, III, and aVF (use the rhythm strip). What is the rhythm?

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Where is the ST elevation? What is the diagnosis?

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What is the lesson of this ECG?

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ECG ____

ECG 9

[Insert image - Garcia ECG 15-9]

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What is the rate, rhythm, and axis?

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Are there any interval abnormalities?

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With a PR this long, what else should you look for?

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Identify the ST changes and Q waves. What is the diagnosis?

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ECG ____

ECG 10

[Insert image - Garcia ECG 15-10]

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What is the rate, rhythm, and axis?

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Identify the ST changes, T waves, and Q waves. What is the diagnosis?

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How do you tell this apart from LVH with strain?

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ECG ____

ECG 11

[Insert image - Garcia ECG 15-11]

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What is the rate, rhythm, and axis?

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Identify the ST elevation, reciprocal changes, and T wave morphology. What is the diagnosis?

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This patient is in distress and hemodynamically unstable. When should you repeat the ECG?

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ECG ____

ECG 12

[Insert image - Garcia ECG 15-12]

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Same patient as ECG 11, less than 10 minutes later. What changed in the QRS?

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Look at the axis. What else is new?

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What is the significance of a new bifascicular block during an AMI?

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ECG ____

ECG 13

[Insert image - Garcia ECG 15-13]

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What is the rate, rhythm, and axis?

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Examine the ST changes. What is the diagnosis?

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What is the conduction abnormality?

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The bifascicular block is old. Do you still need to worry?

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ECG ____

Lateral Wall AMI

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Which leads represent the lateral wall, and what does a high lateral AMI produce?

ECG 14

[Insert image - Garcia ECG 15-14]

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What is the rate, rhythm, and axis?

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Identify the ST changes. What do they suggest?

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What findings suggest LVH?

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Are the lateral T wave changes from LVH with strain or ischemia?

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ECG ____

Inferior Wall AMI

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Which leads represent the inferior wall, and where are its reciprocal changes?

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Why are isolated inferior Q waves usually an old (age-indeterminate) infarct?

ECG 15

[Insert image - Garcia ECG 15-15]

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What is the rate, rhythm, and axis?

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Are there ST changes diagnostic of acute MI?

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Are there contiguous pathologic Q waves?

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What does the R wave progression suggest?

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What are the 8th and last beats?

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ECG ____

ECG 16

[Insert image - Garcia ECG 15-16]

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What is the rate, rhythm, and axis?

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The QRS is wide and bizarre, with an RSR' in V6. What happened? (Hint: something was misplaced)

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Are Q waves in the inferior leads expected with an RBBB?

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What is the first beat?

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ECG ____

Inferolateral AMI

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Which leads are involved in an inferolateral AMI?

ECG 17

[Insert image - Garcia ECG 15-17]

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What is the rate, rhythm, and axis?

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Identify the ST changes. What is the diagnosis?

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Look at aVL. Why is it important?

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Is there evidence of RV involvement?

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ECG ____

ECG 18

[Insert image - Garcia ECG 15-18]

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What is the rate, rhythm, and axis?

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Identify the ST changes and Q waves. What is the diagnosis?

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Look at V2. What could it suggest?

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Why does possible posterior involvement change things?

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ECG ____

ECG 19

[Insert image - Garcia ECG 15-19]

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What is the rate, rhythm, and axis?

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Start with aVL. What do you see, and what would it mean even without inferior ST elevation?

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Identify the ST elevation. What is the diagnosis?

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What findings suggest RV or posterior involvement?

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ECG ____

ECG 20

[Insert image - Garcia ECG 15-20]

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What is the rate, rhythm, and axis?

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Identify the ST changes. What is the leading diagnosis?

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The QRS upstroke looks slurred in the limb leads and V1. Could this be WPW with a pseudoinfarct pattern?

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ECG ____

ECG 21

[Insert image - Garcia ECG 15-21]

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What is the rate and rhythm?

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Are the QRS complexes wide? Is there a bundle branch block?

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Where is the ST elevation and depression? What regions are involved?

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Which came first, the infarct or the arrhythmia? How does it change management?

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ECG ____

Apical AMI

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What is an apical AMI, and which leads are involved?

ECG 22

[Insert image - Garcia ECG 15-22]

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What is the rate, rhythm, and axis?

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Where is the ST elevation? What is the leading diagnosis?

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What is the differential for ST elevation in both I and II?

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How do you sort out that differential?

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ECG ____

ECG 23

[Insert image - Garcia ECG 15-23]

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What is the rate, rhythm, and axis?

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Evaluate the ST elevation and Q waves. What is the diagnosis?

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What is the culprit lesion, and what is at risk?

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There is some PR depression. Could this be pericarditis?

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ECG ____

ECG 24

[Insert image - Garcia ECG 15-24]

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Look at the rhythm strip. What are the odd beats?

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Mentally remove those beats. What is the underlying rhythm?

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Evaluate the ST changes. What is the leading diagnosis?

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The complexes in aVF look odd and V4-V6 look wide. Why?

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What is the approach to a very difficult ECG like this?

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ECG ____

Right Ventricular AMI and Additional Leads

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When and how do you obtain right-sided leads?

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What are the ECG criteria for RV infarction? (not all need to be present)

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What does it mean if the ST depression in V2 is more than half the ST elevation in aVF?

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Why is RVI managed differently?

ECG 25

[Insert image - Garcia ECG 15-25]

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What is the rhythm and axis?

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Evaluate the ST changes. What is the leading diagnosis?

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Is there LVH? Are the biphasic lateral T waves reciprocal to the inferior MI?

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Evaluate the PR interval (see V3). How could it relate to the diagnosis?

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ECG ____

ECG 26

[Insert image - Garcia ECG 15-26]

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What is the rate, rhythm, and axis?

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Is there an inferior MI?

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Which RV infarct criteria are met on the standard 12-lead?

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What precordial ST pattern is common in RVI?

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ECG ____

ECG 27

[Insert image - Garcia ECG 15-27]

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What is the rate, rhythm, and axis?

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Is there an inferior MI with RV involvement? Which criteria are met?

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What is the recommended workflow for RV infarcts?

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ECG ____

Posterior Wall AMI

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How is a posterior MI diagnosed on a standard 12-lead?

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ST depression in V1-V2: how do you tell posterior MI from anterior ischemia or RV strain?

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What is the differential for an increased R:S ratio in V1-V2?

ECG 28

[Insert image - Garcia ECG 15-28]

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What is the rate, rhythm, and axis?

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There is an increased R:S ratio in V1-V2. Work through the differential.

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What other findings support a posterior MI?

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Is there an associated inferior or lateral MI? What would you order?

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ECG ____

ECG 29

[Insert image - Garcia ECG 15-29]

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What is the rate, rhythm, and axis?

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Evaluate the R:S ratio and R wave width in V2. What do they suggest?

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Is there ST depression in V2?

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What other infarct is present, and what does it say about timing?

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Why do posterior, inferior, and RV infarcts occur together?

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ECG ____

Inferoposterior AMI

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How do you diagnose an inferoposterior AMI?

ECG 30

[Insert image - Garcia ECG 15-30]

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What is the rate, rhythm, and axis?

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Is there an inferior MI? Is RV involvement suspected?

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What do V1 and V2 show?

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What completes the pattern? What is the final diagnosis?

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ECG ____

ECG 31

[Insert image - Garcia ECG 15-31]

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What is the rate, rhythm, and axis?

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Identify the ST elevation and reciprocal changes. What do they show?

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Look at V1 and V2. What do they add? Are they reciprocal to the lateral ST elevation?

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Is there RV involvement?

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ECG ____

ECG 32

[Insert image - Garcia ECG 15-32]

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What is the rate, rhythm, and axis?

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What is the conduction abnormality?

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What should the ST segments in V1-V2 normally look like in an LBBB?

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What findings indicate infarction despite the LBBB?

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What is the final diagnosis?

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ECG ____

Inferior-RV-Posterior AMI

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What criteria identify an inferior-RV-posterior AMI?

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Why are these patients so high risk, and what is the usual culprit?

ECG 33

[Insert image - Garcia ECG 15-33]

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What is the rate, rhythm, and axis?

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Which regions are infarcting? What is the evidence for each?

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Compare the ST depression in V2 with the ST elevation in aVF. What does it tell you?

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ECG ____

ECG 34

[Insert image - Garcia ECG 15-34]

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What is the rate, rhythm, and axis?

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Identify the inferior and RV findings.

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The R waves in V1-V2 are not prominent. Is there still evidence of posterior involvement?

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What additional leads should have been obtained?

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ECG ____

ECG 35

[Insert image - Garcia ECG 15-35]

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What is the rate, rhythm, and axis?

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Find the evidence for each of the four regions involved.

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What artery could put this much myocardium at risk? How should you treat?

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ECG ____

ECG 36

[Insert image - Garcia ECG 15-36]

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Evaluate the ST changes. What is the diagnosis?

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Is the small ST elevation in V6 pathologic? Does it meet thrombolytic criteria?

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ECG ____

ECG 37

[Insert image - Garcia ECG 15-37]

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Start with aVL. Why?

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Evaluate the ST changes. What is the diagnosis?

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These changes are subtler than the previous examples. Do they warrant reperfusion?

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What is the differential for an increased R:S ratio in V1-V2?

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ECG ____