Two patients with inferior STEMI: which is the culprit arter
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The present case paper appears in the journal Circulation.

Case 1
A 56-year-old man had arrived by ambulance to the coronary care unit. The patient was on treatment for hypertension; he did not smoke and had no history of angina pectoris or myocardial infarction. He had experienced severe retrosternal chest pain for 1 hour before admission.

The ECG revealed ST-segment elevation in inferior leads and in V5 and V6 and ST depression in aVL, and V1 through V3. V4 was obviously incorrectly recorded (Figure 1).

Case 2
The second case was a 79-year-old man who had arrived by ambulance to the coronary care unit after experiencing chest pain radiating to the neck, starting 1½ hours before arrival. He was a smoker but had no history of diabetes mellitus, hypertension, or ischemic heart disease. The ECG demonstrated ST-segment elevation in inferior leads and in V5 and V6 and ST depression in V1 and V2 (Figure-2).

Both patients were taken to the catheterization laboratory and underwent percutaneous coronary intervention.

What is the culprit artery in each patient? Can you recognize the unusual lead presentation on the ECG?

Response to ECG Challenge:-
Note that both ECGs are presented with the Cabrera sequence for the limb leads. Unlike the classic lead presentation, which shows limb leads in a noncontiguous, nonanatomic order (I, II, III and aVR, aVL, aVF), the limb leads in the Cabrera display are presented in a left/cranial to right/caudal order (Figure 3).

In this way, the relationships between the limb leads are more easily understood, especially when learning electrocardiographic interpretation. In the Cabrera display, lead aVR is replaced by its inverted version, –aVR, which is presented in its logical place, between leads I and II .

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