Letter by Casella Regarding Article, “Masking Inferior Infarction by Anterior Myocardial Injury”
To the Editor:
I read with great interest the article by Deng and Das.1 The changes in the limb leads in the tracing of Figure 2 of their article, as compared with Figures 1 and 3, are very similar to those that we see with reversal of the left-arm and left-leg cables.2 The features suggesting a lead-placement error are particularly evident when comparing Figures 2 and 3. In Figure 2, “lead I” is actually lead II, “lead II” is lead I, “aVL” is aVF, and “aVF” is aVL. Lead III is upside down (P, QRS, and T have reversed their polarity). The P-wave morphology in leads I, II, aVL, and aVF also suggests a lead reversal.
In a large hospital practice, a cause for the sudden disappearance and reappearance of an inferior infarction, in the absence of transient conduction abnormalities such as left anterior fascicular block or left bundle-branch block, is indeed the reversal of the left-limb cables. It is difficult to understand how an anterior myocardial injury without QRS changes would mask the QRS changes of an inferior infarction. If there was no lead reversal, this would indeed be a most unusual and interesting case.