Localisation is always difficult with such subtle changes, and serial ECGs (ideally every 10 minutes) are of utmost importance for clarification. However, it is unclear at this stage where the maximum ST depression will be when the full-blown ST vector becomes apparent. ST depression extends to V4-6 which may be reciprocal change to evolving inferior infarction, or due to diffuse subendocardial ischaemia in the context of undiagnosed triple vessel disease. Flattened ST segment in V2 is abnormal and concerning for “posterior” extension of infarct territory with right ventricular (RV) involvement the accuracy of serial ECGs in acute MI (sensitivity 39, specificity 88).5 As part of the Myocardial Infarction Triage and Intervention Project, the inves-tigators found that when compared with a single ECG, serial exams increased the diagnostic sensitivity for acute coronary syndrome from 34 to 46 with a reduction in specificity from 96.
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