ECG Case 64: Old Anterior Myocardial Infarction

ECG Interpretation

  • Sinus rhythm, rate 48/min
  • Normal axis
  • Small R waves in leads V2–V4 and a normal (tall) R wave in lead V5

Poor R wave progression, suggesting an old anterior myocardial infarction

Clinical interpretation

The small R waves in leads V2–V4 and the ‘sudden’ appearance of a normal R wave in lead V5 is called ‘poor R wave progression’, and despite the absence of Q waves this probably indicates an old anterior infarction. An alternative explanation might be poor lead positioning.

What to do ?

The ECG should be repeated, to ensure proper positioning of the chest leads. A serial troponins should be obtained to see if there’s acute MI. An echocardiogram, and a chest X-ray are needed, to see if left ventricular impairment is responsible for the breathlessness, and stress echocardiography or perfusion imaging are needed, to investigate the chest pain.

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