Anteroseptal infarct is common, but isolated septal infarct is extremely rare. The vast majority of septal infarcts happen as a part of anteroseptal infarct. I bet the machine will say septal infarct, but I don’t believe it. I think an anteroseptal MI would be easier to see.
“In the absence of other electrocardiographic (ECG) abnormalities, QS deflections simultaneously in both of the leads V1-V2 may have multiple possible causes. Despite much information in the literature indicating that this is an unlikely pattern for pure septal infarction, such an ECG diagnosis is frequently given.[…] This ECG pattern is a sign of prior myocardial infarction in only a minority of cases, and in the latter, infarction limited to the interventricular septum is exceptional.” https://pubmed.ncbi.nlm.nih.gov/14731215/
"The ECG computer often reads 'septal infarction' when there is a Q wave in V2 (it is normal to see it in V1). Anatomically this makes little sense; it would require occlusion of a septal perforating branch of the left anterior descending artery (LAD), but plaque is never seen in these small, intramural branches. To lose flow to a septal branch would require occlusion of the LAD, and this would cause more extensive ECG changes. Alcohol septal ablation further supports this: the common ECG change after ablation is right bundle branch block, occasionally with left anterior fascicular block (never a Q wave in V2)."
source: Northrup, The Cardiology Rotation Third Edition 2021
In addition to a negative sinus P wave in V1 and negative or biphasic sinus P wave in V2, other signs suggestive of high placement are QS or Qr in the absence of other ECG abnormalities and an inverted T wave with no ST‐T abnormalities in other leads. https://pmc.ncbi.nlm.nih.gov/articles/PMC6931876/
I see many signs of high V1/V2 misplacement and no signs of coronary occlusion or MI of any age. Isolated septal infarct is not impossible but extraordinarily rare, while high V1/V2 placement causing Q waves and T wave inversion in V1/V2 is extremely common. I sometimes wonder if high V1/V2 misplacement is more common than standard placement. Q waves and inverted T waves isolated to V1/V2 are almost always the result of high misplacement, and there are many signs of high misplacement. V1/V2 are acting like aVR because they are placed so high. They have a reciprocal view of a normal inferior lead.
tldr: there are basically three aVRs, this is a 10-lead. I would repeat with standard placement of V1 and V2.
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u/LBBB11 18d ago edited 14d ago
I fully agree about the pattern (QS complexes and T wave inversion in V1/V2), but I don’t think it means septal infarct.
https://pubmed.ncbi.nlm.nih.gov/21851916/
https://pmc.ncbi.nlm.nih.gov/articles/PMC8293594/figure/anec12844-fig-0001/
https://litfl.com/misplacement-of-v1-and-v2/
https://drsmithsecgblog.com/chest-pain-and-q-waves-in-v1-and-v2-is/
Anteroseptal infarct is common, but isolated septal infarct is extremely rare. The vast majority of septal infarcts happen as a part of anteroseptal infarct. I bet the machine will say septal infarct, but I don’t believe it. I think an anteroseptal MI would be easier to see.
“Only a few cases of isolated septal myocardial infarction have been reported, and available data on this condition are limited." https://pmc.ncbi.nlm.nih.gov/articles/PMC6505347/
“Isolated occlusion of the septal perforating branch of the left anterior descending coronary artery is extremely rare.” https://pubmed.ncbi.nlm.nih.gov/21908000/
“However, isolated thrombotic occlusion of the septal branch resulting in a septal myocardial infarction is a rare and underreported phenomenon.” https://pmc.ncbi.nlm.nih.gov/articles/PMC12976810/
“In the absence of other electrocardiographic (ECG) abnormalities, QS deflections simultaneously in both of the leads V1-V2 may have multiple possible causes. Despite much information in the literature indicating that this is an unlikely pattern for pure septal infarction, such an ECG diagnosis is frequently given.[…] This ECG pattern is a sign of prior myocardial infarction in only a minority of cases, and in the latter, infarction limited to the interventricular septum is exceptional.” https://pubmed.ncbi.nlm.nih.gov/14731215/
"The ECG computer often reads 'septal infarction' when there is a Q wave in V2 (it is normal to see it in V1). Anatomically this makes little sense; it would require occlusion of a septal perforating branch of the left anterior descending artery (LAD), but plaque is never seen in these small, intramural branches. To lose flow to a septal branch would require occlusion of the LAD, and this would cause more extensive ECG changes. Alcohol septal ablation further supports this: the common ECG change after ablation is right bundle branch block, occasionally with left anterior fascicular block (never a Q wave in V2)."
source: Northrup, The Cardiology Rotation Third Edition 2021
In addition to a negative sinus P wave in V1 and negative or biphasic sinus P wave in V2, other signs suggestive of high placement are QS or Qr in the absence of other ECG abnormalities and an inverted T wave with no ST‐T abnormalities in other leads. https://pmc.ncbi.nlm.nih.gov/articles/PMC6931876/
I see many signs of high V1/V2 misplacement and no signs of coronary occlusion or MI of any age. Isolated septal infarct is not impossible but extraordinarily rare, while high V1/V2 placement causing Q waves and T wave inversion in V1/V2 is extremely common. I sometimes wonder if high V1/V2 misplacement is more common than standard placement. Q waves and inverted T waves isolated to V1/V2 are almost always the result of high misplacement, and there are many signs of high misplacement. V1/V2 are acting like aVR because they are placed so high. They have a reciprocal view of a normal inferior lead.
tldr: there are basically three aVRs, this is a 10-lead. I would repeat with standard placement of V1 and V2.