A 55-year-old man presents with chest pain. ECG shows ST elevation in V1-V4 with ST depression in II, III, and aVF. Primary PCI is performed and stent placed in the LAD. Which coronary anatomy pattern is suggested by this ECG pattern?

• A Mid LAD occlusion with reciprocal changes in the inferior leads ✓
• B Dominant right coronary artery with RCA supplying the inferior wall
• C Dominant left coronary artery with wrap-around LAD supplying the inferior wall
• D Left main artery occlusion producing global ischaemia

Explanation

ST elevation in V1-V4 represents anterior STEMI from LAD occlusion, and the ST depression in II, III, and aVF are reciprocal changes — mirror image of the ischaemia seen from the opposite wall perspective. Reciprocal ST depression in inferior leads is a common finding in anterior STEMI and is an independent marker of larger infarct size and worse prognosis. A wrap-around LAD (Type III) producing an inferior STEMI would show primary ST elevation in the inferior leads, not just reciprocal changes. Left main occlusion typically shows widespread ST changes.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.