In Reply: We thank Dr. Madias for his letter. We agree that doing a second electrocardiogram to inspect V 3R, V 4R, and V 7 to the left of the spine and V 9 to the right of the spine may provide important additional information that supports the diagnosis of acute MI. When clinical suspicion is high and the standard 12-lead electrocardiogram shows only minimal changes, then additional lead placement may be useful. Some other situations were not covered in our paper but are worthy of consideration when looking for electrocardiographic evidence of acute MI, eg:
- Patients with left main disease may demonstrate modest ST-T elevation in lead AVR with diffuse ST-T depression when having an acute MI.
- Patients with only T-wave-flattening in AVL may be having an acute MI due to isolated circumflex coronary disease.
Again, we thank Dr. Madias for his interest in our paper. We welcome his suggestion and hope that our response will be of some value to physicians responsible for making the very important decision to send a patient urgently to the cardiac catheterization laboratory.