Clinical Policy: Indications for Reperfusion Therapy in Emergency Department Patients with Suspected Acute Myocardial Infarction  Francis M. Fesmire, MD (Subcommittee Chair), William J. Brady, MD, Sigrid Hahn, MD, Wyatt W. Decker, MD, Deborah B. Diercks, MD, Chris A. Ghaemmaghami, MD, Devorah Nazarian, MD, Andy S. Jagoda, MD (Clinical Policies Committee Chair)  Annals of Emergency Medicine  Volume 48, Issue 4, Pages 358-383 (October 2006) DOI: 10.1016/j.annemergmed.2006.07.006 Copyright © 2006 American College of Emergency Physicians Terms and Conditions

Figure 1 A, Isolated right ventricular AMI. Note the diagnostic ST-segment elevation in leads III and V1, nondiagnostic ST-segment in lead II, and ST depression with terminal upright T waves in leads I and aVL (ie, reciprocal changes from right lateral injury). Since lead V1 injury = V2R injury, and right lateral injury = V6R injury, theoretically this patient should have injury in leads V2R to V6R. B, Right ventricular leads in same patient confirming injury in leads V2R through V6R. Annals of Emergency Medicine 2006 48, 358-383DOI: (10.1016/j.annemergmed.2006.07.006) Copyright © 2006 American College of Emergency Physicians Terms and Conditions

Figure 2 A, 12-lead ECG demonstrating an isolated acute posterior AMI. Note the prominent R wave, horizontal ST-segment depression, and upright T wave in leads V3 through V6. B, Upside down mirror image of Figure 2A representing classical ST-segment elevation in leads V3 through V6. Annals of Emergency Medicine 2006 48, 358-383DOI: (10.1016/j.annemergmed.2006.07.006) Copyright © 2006 American College of Emergency Physicians Terms and Conditions

Figure 3 12-lead ECG demonstrating electrocardiographic AMI in the setting of LBBB. Note the concordant ST-segment elevation in leads I, aVL, V5 and V6. Also note the excessive discordant ST-segment elevation in leads V1 through V4. Annals of Emergency Medicine 2006 48, 358-383DOI: (10.1016/j.annemergmed.2006.07.006) Copyright © 2006 American College of Emergency Physicians Terms and Conditions

Figure 4 AMI in the presence of RBBB. Note the pseudonormalization of ST segments in lead V1 with concordant ST segment elevation ≥1 mm in leads V2 through V4. Also note early Q wave formation in leads V1 through V5. Unlike LBBB, anterior Q waves are not obscured by the presence of RBBB. Annals of Emergency Medicine 2006 48, 358-383DOI: (10.1016/j.annemergmed.2006.07.006) Copyright © 2006 American College of Emergency Physicians Terms and Conditions

Figure 5 Number of extra lives saved per 1,000 patients treated with fibrinolytics at different time treatment delays from symptom onset. From Terkelsen CJ, Lassen JF, Norgaard BL, et al. Are we underestimating the full potential of early thrombolytic treatment in patients with acute myocardial infarction? Heart. 2003;89:483-484. Reproduced with permission from the BMJ Publishing Group. Annals of Emergency Medicine 2006 48, 358-383DOI: (10.1016/j.annemergmed.2006.07.006) Copyright © 2006 American College of Emergency Physicians Terms and Conditions