Leads II, III and aVF show inferior wall.

  Observation of q or Q waves suggest a diagnosis of OLD inferior wall myocardial infarction (MI).

  Absence of ST segment elevation in inferior leads also contribute to the diagnosis of OLD inferior MI.

      However, the reverse is not true. ST segment elevation may be seen in ACUTE MI as well as in

      OLD myocardial infarctions with left ventricular aneurysms.

  In patients undergoing early coronary recanalization, the development of q or Q waves may not be

      observed. In such cases, observation of symmetrical negative T waves in leads II, III and aVF may

      suggest the diagnosis of OLD MI.

  Unlike old anterior MI, the ECG findings in patients with OLD Inferior MI may fade out in the following

      years. This is especially true for the patients who have been intervened very early.




ECG 1. The ECG above belongs to a 67 years old man who had underwent coronary bypass greft operation after inferior wall
myocardial infarction. The ECG was recorded when the patient was asymptomatic. Observation of Q waves in leads II, III and
aVF show OLD inferior wall myocadial infarction. Positive T waves in inferior leads also support the diagnosis of OLD inferior
wall myocardial infarction.

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ECG 2a. This ECG belongs to a 52 years old man who had undergone stenting of the right coronary artery for the treatment of
acute inferior wall myocardial infarction 1 year ago. The ECG above was recorded during a routine control and the patient
was asymptomatic. There are Q waves and negative T waves in the inferior leads. Lacking ST elevation and typical chest pain,
these ECG findings suggest OLD inferior wall myocardial infarction. The patient also has dextrocardia. Because of
dextrocardia, QRS complex and T wave are upright in lead aVR while they are negative in lead I . This finding is not due to
arm lead reversal since there is no expected R wave progression in the chest leads. Contrarily, the amplitude of the R wave
decreases from C1 to C6.

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ECG 2b. The above ECG belongs to the same patient but was recorded after the electrodes were symmetrically placed on the
right chest. The ECG now shows proper R wave progression . Old inferior myocardial infarction and abnormal appearance in
lead aVR persists.

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ECG 3. This patient had inferior mycoardial infarction 10 years ago. Leads III and aVF show Qr pattern while lead II shows
qr pattern .

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ECG 4. Q waves in leads II, III and aVF show old inferior wall myocardial infarction.

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ECG 5. Q waves and negative T waves in leads II, III and aVF show old inferior wall myocardial infarction. This patient had
experienced acute inferior wall myocardial infarction 4 weeeks ago.

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ECG 6. The ECG above, belongs to a man who had acute inferior wall myocardial infarction one month ago. A stent was
implanted to his right coronary artery within the first hour of the infarction. Because of the early revascularization, Q waves
are not formed in inferior leads . The only evidence of an old inferior wall myocardial infarction in this patient is
symmetrical negative T waves in leads II, III and aVF .

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ECG 7. The above ECG belongs to a 29 years old man who experienced acute inferior wall myocardial infarction 4 weeks ago.
The patient received thrombolytic therapy in the first hour of the infarction. Early recanalization prevented development of
Q waves in inferior leads. Only the negative T waves in leads III and aVF can be the evidence of an OLD inferior myocardial
infarction. Leads III and aVF have rS complex. After the initial medical therapy, the patient underwent coronary
angiography and a stent was implanted to the proximal right coronary artery. The other coronary arteries of this man were
normal.

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ECG 8. The ECG above was recorded before the 63 years-old male patient underwent coronary artery bypass graft operation.
He previously had acute inferior myocardial infarction. RBBB does not mask the diagnosis of old inferior myocardial infarction.

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ECG 9. The ECG above belongs to a 59 years-old man who previously had acute inferior wall myocardial infarction.
RBBB does not mask the diagnosis of old inferior myocardial infarction.

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ECG 10. The ECG above belongs to an 85 years-old man who had acute inferior wall myocardial infarction in the past.
The ECG shows RBBB and APC. The PR interval i,s at the upper limit of normal.
RBBB does not mask the diagnosis of old inferior wall myocardial infarction.

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ECG 11a. The ECG above belongs to a 61 years-old man with subacute inferior myocardial infarction.
His coronary angiography showed proximal complete obstruction of the right coronary artery (RCA).
The LAD and Cx arteries were normal.
Shortly after recording of the above ECG, his RCA was successfully opened by a stent.
There is also right bundle branch block (RBBB).

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ECG 11b. Above is the same patient's ECG which was recorded 3 years after the ECG 22a.
Right bundle branch block persists.
The T wave negativity in lead aVF has disappeared and the amplitude of the q wave has decreased.
T wave negativity in lead III persists.

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ECG 12. The ECG above belongs to a 62 years-old man who had previously undergone coronary artery bypass surgery.
Before the operation, he had experienced acute inferior myocardial infarction due to proximal right coronary artery occlusion.
Leads III and aVF show only small q waves.
The rhythm is atrial fibrillation.
In patients with small q waves and oscillating baseline due to (f waves of) atrial fibrillation, it may be difficult to detect the
small q waves at first glance (as is the case in lead III of the above ECG).

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ECG 13. The ECG above is from a 68 years-old woman who had previously undergone coronary artery bypass graft surgery.
Prior to the operation, she had experienced acute inferior wall myocardial infarction.
However, leads II, III and aVF show only very small q waves.





ECG 14. Above ECG is from a 51 years-old man with old inferior myocardial infarction and previous coronary artery bypass
surgery. He also has a permanent cardiac pacemaker operating in the VDD mode, but the pacemaker spikes are not clear.
Wide QRS complexes are due to the pacemaker stimuli.
These pacemaker beats are not suitable to look for ECG signs of myocardial ischemia or infarction.
In these patients, you have to wait for the normally conducted, narrow supraventricular beats to diagnose ischemia or infarction.
The q waves of narrow QRS complexes in leads III and aVF suuggest the diagnosis of old inferor wall myocardial infarction.
ECHOcardiography showed inferior wall akinesia (old inferior wall myocardial infarction).

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ECG 15. Above ECG is from a 50 years-old woman with old inferior myocardial infarction and previous coronary artery bypass
graft surgery. Before surgery, her RCA and Cx coronary arteries were totally occluded.
Right bundle branch block (RBBB) and q waves in inferior leads are seen.

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ECG 16. Above ECG is from a 87 years-old woman with old inferior myocardial infarction due to occlusion of the right
coronary artery (RCA). Q waves are seen in inferior leads. Leads III and aVF also show negative T waves.
The rhythm is atrial fibrillation.

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ECG 17. The ECG above is from a 67 years-old man. In the past, he had experienced acute inferior wall
myocardial infarction due to total occlusion of the right coronary artery (RCA).
Leads II. III and aVF show q waves, ST segment depression and negative T waves.
This patient also has moderate aortic valve stenosis which is the cause of increased QRS voltage in chest leads.
Leads V3 and V4 show ST segment depression and negative T waves which are due to stenosis of his diagonal
coronary artery. Left ventricular hypertrophy alone cannot explain these changes in leads V3 and V4.




ECG 18. The ECG above belongs to a 42 years-old man with old inferior myocardial infarction due to right coronary artery (RCA)
obstruction. ECHOcardiography showed mild left ventricular systolic dysfunction with an ejection fraction of 45%.
Leads II, III avF show q waves while lead III shows negative T wave.

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ECG 19a. The ECG above belongs to a 60 years-old man with old infero-postero-lateral myocardial infarction.
His ECHOcardiography showed hypokinesia of inferior, posterior and lateral walls of the left ventricle
with an ejection fraction of 38% (left ventricular systolic dysfunction).
Do you see any abnormality in this ECG?

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ECG 19b. The compact ECG above is the summary report of ECG 6a. The ECG's computer also reported it as "normal".




ECG 20a. The ECG above belongs to a 46 years-old man with mild mitral stenosis and frequent attacks of palpitation.
At first glance, the q waves in inferior leads and tall R waves in lead V1 suggest a diagnosis of old inferoposterior
myocardial infarction. The delta waves in some patients with WPW syndrome may imitate q waves suggesting old myocardial
infarction.
In the above ECG, lead V3 shows a giant delta wave, while leads V4 and aVL show subtle delta waves.

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ECG 20b. The above ECG was recorded during one of his palpitation attacks.
During the tachycardia, AV-node, His bundle and Purkinje fibers are used for conduction to the ventricles
and the accessory pathway is used for re-exciting the atria: orthodromic AVRT (AV Reciprocating Tachycardia).
Because of this, delta wave is not seen during the tachycardia.
Because of this, leads III and aVF do not show Q waves (delta wave) during the tachycardia.
Because of this, tall R wave in lead V1 is not seen during the tachycardia.
Because of this, the ECG above looks very similar to the post-ablation resting ECG below (ECG 20c).

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ECG 20c. Electrophysiologic study showed left posterolateral accessory pathway in this patient.
The above ECG was recorded after ablation of the accessory pathway.
Inferior leads do not show q waves anymore. No more suggestion of old inferoposterior myocardial infarction.
Lead V3, V4 and aVL also do not show delta waves any more.

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ECG 21. The ECG above belongs to a 39 years-old man with Wolff-Parkinson-White syndrome
Almost all leads show delta waves, including III and aVF.
At first glance, the delta waves in III and aVF may suggest the diagnosis of old inferior wall myocardial infarction.
However, the delta waves in this patient mimick q waves suggesting old inferior myocardial infarction.
In fact, he has not experienced acute inferior wall myocardial infarction in the past.

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ECG 22. The ECG above belongs to a 71 years-old man with old inferior wall myocardial infarction and
left ventricular systolic dysfunction (left ventricular ejection fraction was 35%).
q waves in inferior leads denote old inferior wall myocardial infarction.
Despite the presence of q waves, no negative T waves are seen in inferior leads .
Left side of the tracing shows tremor artifact.

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ECG 23a. Above is an ECG from a 40 years-old woman.
Inferior leads show q waves and ST segment elevation. Only lead III shows negative T waves.
This ECG was recorded 7 days after she had experienced acute inferior wall myocardial infarction.
Coronary angiography showed total occlusion of the right coronary artery (RCA) at its origin.
It was successfully oppened by a stent within one hour after the onset of chest pain.
Her other coronary arteries were normal.
Early intervention resulted in preservation of her left ventricular systolic function (normal Ejection Fraction).

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ECG 23b. Above ECG belongs to the same woman.
It was recorded 2 months after her acute inferior wall myocardial infarction.
Inferior leads still show q waves. Lead III still shows negative T waves.
Inferior leads show ST elevation but the amplitude is decreased.

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