Anterior Wall Myocardial Infarction
T-wave inversion in leads V1-V4 with ST depression in aVF strongly suggests anterior wall myocardial infarction, not posterior wall involvement, and requires immediate evaluation for critical proximal left anterior descending (LAD) artery stenosis. 1, 2
ECG Pattern Recognition and Diagnostic Criteria
The combination you describe represents a classic anterior wall ischemic pattern that demands urgent attention:
T-wave inversion in V1-V4 meets the diagnostic requirement of "two or more contiguous leads" observing the same myocardial territory (anterior wall of the left ventricle), which is the ACC/AHA standard for diagnosing myocardial ischemia. 1
Deep T-wave inversion (≥0.5 mV) in V2-V4 with QT prolongation represents the most dangerous pattern—this is Wellens' syndrome, indicating severe stenosis of the proximal LAD with collateral circulation and a pre-infarct state. 3, 1
ST depression in aVF (inferior leads) accompanying anterior T-wave changes represents reciprocal changes from anterior wall ischemia, NOT a separate inferior or posterior process. 4, 5
Why This is NOT Posterior Wall MI
The evidence clearly distinguishes this pattern from posterior infarction:
Posterior MI presents with ST depression in V1-V3 with upright (positive) T-waves, not T-wave inversion. 3 The ACC/AHA guidelines specifically state that horizontal ST depression with upright precordial T-waves indicates posterior injury, whereas downsloping ST depression with T-wave inversion indicates anterior non-STEMI. 3
Your pattern of T-wave inversion in V1-V4 with inferior ST depression is the opposite of posterior MI—it indicates anterior wall ischemia with reciprocal inferior changes. 4
Research demonstrates that isolated inferior ST depression is actually an early sign of anterior wall AMI in 60% of cases, with the LAD as the culprit artery. 4
Immediate Management Algorithm
Step 1: Obtain serial ECGs every 15-30 minutes or continuous 12-lead monitoring, as dynamic changes are common and a single ECG provides only a snapshot. 1
Step 2: Measure cardiac biomarkers (troponin) immediately and compare with prior ECGs to determine if findings are new or chronic. 2
Step 3: Perform urgent echocardiography to assess for anterior wall hypokinesis, which combined with deep T-wave inversion in V2-V3 indicates high risk requiring urgent angiography within 120 minutes. 1
Step 4: Arrange urgent coronary angiography if the patient has:
- Deep T-wave inversion (≥2 mm) in V2-V3 with QT prolongation 1
- Dynamic ST changes (≥0.5 mm) during symptoms 1
- Anterior wall hypokinesis on echocardiography 1
Critical Pitfalls to Avoid
Do not dismiss this pattern as "nonspecific" T-wave changes. The ACC warns that misinterpretation of subtle ECG findings occurs in a significant percentage of undiagnosed myocardial infarctions. 1
Do not wait for ST elevation to develop. This pattern represents a pre-infarct state where patients have a high risk of extensive anterior infarction if not urgently revascularized. 3, 1
Do not interpret inferior ST depression as indicating a separate inferior or posterior process. Research shows this is typically reciprocal change from anterior ischemia, with the LAD as the culprit in 60% of cases. 4
Do not obtain posterior leads (V7-V9) in this case, as the pattern clearly indicates anterior wall pathology, not posterior MI. 1, 2 Posterior leads would be indicated if you saw ST depression in V1-V3 with upright T-waves, which is not your pattern. 3
Prognostic Implications
If this pattern represents Wellens' syndrome (deep T-wave inversion with QT prolongation), the patient has critical proximal LAD stenosis and will likely develop extensive anterior wall STEMI without urgent intervention. 3, 1
The presence of inferior ST depression with anterior T-wave changes indicates more extensive anterior ischemia and potentially prediagonal LAD occlusion. 5
Recent research demonstrates that T-wave inversions in the inferior leads can precede development of inferior-posterior STEMI, but in your case with V1-V4 involvement, the primary territory is anterior. 6