Cardiac Wall Involvement with ST Elevation in V2-4, III, and aVF

Primary Interpretation

The American Heart Association indicates that the combination of ST elevation in leads V2-4 and leads III, aVF creates a distinctive pattern that requires careful interpretation, involving both the anterior and inferior walls of the left ventricle, representing either a "wraparound" distal LAD occlusion or, less commonly, proximal RCA occlusion with right ventricular extension 1
The American College of Cardiology recommends recognizing that ST elevation in leads V2-4 indicates anterior wall involvement 1
The European Society of Cardiology states that ST elevation in leads III and aVF indicates inferior wall involvement 2, 3

The American Heart Association suggests that a distal LAD occlusion with "wraparound" anatomy extending beyond the apex to supply the inferior wall is the most common cause of this pattern, with the ST-segment vector oriented more inferiorly when the occlusion is distal, causing ST elevation in both anterior and inferior leads 1
The American College of Cardiology indicates that a proximal RCA occlusion with right ventricular involvement extending anteriorly is a less common cause, with the spatial ST vector directed inferiorly, to the right, AND anteriorly 4

The European Society of Cardiology recommends recognizing that greater ST elevation in lead III than lead II, and ST depression in leads I and aVL, favors proximal RCA occlusion 2, 3
The American Heart Association states that progressive ST elevation pattern in precordial leads favors distal LAD occlusion 1
The American College of Cardiology suggests that ST elevation in V1 ≥ V3, and lack of progressive ST elevation from V1 to V3, also favors proximal RCA occlusion 2, 3

The American College of Cardiology recommends recording right-sided chest leads V3R and V4R immediately in all patients with this pattern, as ST elevation in right-sided leads resolves within 10 hours in 50% of patients 2, 3
The European Society of Cardiology indicates that these patients have smaller infarct size, but higher mortality risk if RV infarction is present, and are at high risk for ventricular septal rupture 3