Posterior myocardial infarction is myocardial infarction involving the posterior left ventricular myocardium. It is commonly clinically important because standard 12-lead electrocardiography does not directly record the posterior wall; posterior injury can therefore appear as reciprocal anterior precordial ST-segment depression and may require posterior leads V7-V9, occlusion-MI pattern recognition, or urgent angiography to avoid delayed reperfusion.
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name: Posterior Myocardial Infarction
creation_date: "2026-05-06T11:55:45Z"
updated_date: "2026-05-06T12:15:42Z"
description: >-
Posterior myocardial infarction is myocardial infarction involving the
posterior left ventricular myocardium. It is commonly clinically important
because standard 12-lead electrocardiography does not directly record the
posterior wall; posterior injury can therefore appear as reciprocal anterior
precordial ST-segment depression and may require posterior leads V7-V9,
occlusion-MI pattern recognition, or urgent angiography to avoid delayed
reperfusion.
category: Complex
disease_term:
preferred_term: posterior myocardial infarction
term:
id: MONDO:0003672
label: posterior myocardial infarction
parents:
- Myocardial infarction
- Cardiac disorder
synonyms:
- True posterior myocardial infarction
- True posterior wall infarction
- Posterior MI
prevalence:
- population: Acute coronary syndrome presentations
percentage: 3-7
notes: >-
This estimate refers to isolated posterior myocardial infarction in acute
coronary syndrome, not all posterior-wall involvement accompanying inferior
or lateral infarction.
evidence:
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
True isolated posterior myocardial infarction is an uncommon finding of
acute coronary syndrome, with an incidence rate of 3–7%.
explanation: >-
The case-series abstract provides an incidence range for isolated
posterior myocardial infarction among acute coronary syndrome
presentations.
environmental:
- name: Atherosclerotic cardiovascular risk profile
presence: Positive
description: >-
Posterior myocardial infarction is usually a regional presentation of
myocardial infarction, so modifiable and metabolic atherosclerotic risk
factors for type 1 myocardial infarction, including LDL cholesterol,
smoking, chronic kidney disease, diabetes, hypertension, and familial
hypercholesterolaemia, are relevant risk contexts.
evidence:
- reference: DOI:10.3390/ijms25137295
reference_title: From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion
supports: SUPPORT
evidence_source: OTHER
snippet: >-
Factors predisposing to its occurrence include, among others, high levels
of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette
smoking, chronic kidney disease (CKD), diabetes mellitus (DM),
hypertension, and familial hypercholesterolaemia (FH).
explanation: >-
This review lists major risk factors for type 1 myocardial infarction,
which is the usual atherothrombotic context for posterior MI.
pathophysiology:
- name: Atherosclerotic plaque disruption
description: >-
Rupture or erosion of an atherosclerotic coronary plaque can initiate acute
coronary syndrome by exposing thrombogenic plaque contents and damaged
endothelium to circulating blood.
cell_types:
- preferred_term: endothelial cell
term:
id: CL:0000115
label: endothelial cell
- preferred_term: vascular smooth muscle cell
term:
id: CL:0000359
label: vascular associated smooth muscle cell
locations:
- preferred_term: coronary artery
term:
id: UBERON:0001621
label: coronary artery
downstream:
- target: Coronary thrombosis and occlusion
description: >-
Plaque disruption creates the local substrate for platelet deposition,
coagulation cascade activation, and thrombus growth.
evidence:
- reference: DOI:10.1152/japplphysiol.00017.2011
reference_title: Thrombosis, physical activity, and acute coronary syndromes.
supports: SUPPORT
evidence_source: OTHER
snippet: >-
Acute coronary syndromes (ACS) are common, life-threatening cardiac
disorders that typically are triggered by rupture or erosion of an
atherosclerotic plaque.
explanation: >-
This supports plaque rupture or erosion as a common initiating event in
acute coronary syndromes.
- name: Coronary thrombosis and occlusion
description: >-
After plaque disruption, platelet deposition and coagulation cascade
activation form a platelet-fibrin thrombus. When this thrombus obstructs a
posterior-wall supplying coronary artery, such as the circumflex or right
coronary artery, it causes posterior myocardial ischemia or infarction.
cell_types:
- preferred_term: platelet
term:
id: CL:0000233
label: platelet
biological_processes:
- preferred_term: platelet activation
modifier: INCREASED
term:
id: GO:0030168
label: platelet activation
- preferred_term: blood coagulation
modifier: INCREASED
term:
id: GO:0007596
label: blood coagulation
- preferred_term: inflammatory response
modifier: INCREASED
term:
id: GO:0006954
label: inflammatory response
locations:
- preferred_term: coronary artery
term:
id: UBERON:0001621
label: coronary artery
downstream:
- target: Posterior myocardial ischemic cell death
description: >-
Persistent coronary flow obstruction deprives posterior left ventricular
myocardium of oxygen and substrate, causing ischemic cardiomyocyte injury
and infarction.
evidence:
- reference: DOI:10.1152/japplphysiol.00017.2011
reference_title: Thrombosis, physical activity, and acute coronary syndromes.
supports: SUPPORT
evidence_source: OTHER
snippet: >-
Platelet deposition and activation of the blood coagulation cascade in
response to plaque disruption lead to the formation of a platelet-fibrin
thrombus, which can grow rapidly, obstruct coronary blood flow, and cause
myocardial ischemia and/or infarction.
explanation: >-
This directly links platelet activation, coagulation, coronary flow
obstruction, and myocardial ischemia/infarction.
- reference: DOI:10.1093/ehjqcco/qcad027
reference_title: "Occlusion of the infarct-related coronary artery presenting as acute coronary syndrome with and without ST-elevation: impact of inflammation and outcomes in a real-world prospective cohort"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Hs-CRP, lymphocyte, and neutrophil counts were independent predictors of
total IRA occlusion, suggesting a possible role of systemic inflammation
in the detection of TCO irrespective of ECG presentation.
explanation: >-
This clinical cohort supports an inflammatory signal associated with total
infarct-related artery occlusion.
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Coronary angiography revealed a total/critical occlusion of the proximal
circumflex coronary artery in all three cases.
explanation: >-
This posterior-MI case series supports proximal circumflex occlusion as a
posterior-wall culprit vessel pattern.
- name: Posterior myocardial ischemic cell death
description: >-
Coronary occlusion reduces oxygen delivery to posterior left ventricular
myocardium. Ischemia disrupts calcium handling and mitochondrial function in
cardiomyocytes; reperfusion is essential for tissue salvage but can add ROS
and ionic imbalance, with necrosis and apoptosis contributing to infarcted
myocardium.
cell_types:
- preferred_term: cardiac muscle cell
term:
id: CL:0000746
label: cardiac muscle cell
biological_processes:
- preferred_term: response to hypoxia
modifier: INCREASED
term:
id: GO:0001666
label: response to hypoxia
- preferred_term: apoptotic process
modifier: INCREASED
term:
id: GO:0006915
label: apoptotic process
locations:
- preferred_term: posterior left ventricular myocardium
term:
id: UBERON:0002349
label: myocardium
- preferred_term: heart left ventricle
term:
id: UBERON:0002084
label: heart left ventricle
downstream:
- target: Posterior electrocardiographic injury pattern
description: >-
Posterior-wall injury is reflected by posterior-lead ST elevation and by
reciprocal anterior precordial ST depression on standard 12-lead ECG.
evidence:
- reference: DOI:10.1111/jcmm.15127
reference_title: Mitochondrial and mitochondrial-independent pathways of myocardial cell death during ischaemia and reperfusion injury
supports: SUPPORT
evidence_source: OTHER
snippet: >-
Acute myocardial infarction causes lethal injury to cardiomyocytes during
both ischaemia and reperfusion (IR).
explanation: >-
This links acute MI to lethal cardiomyocyte injury during ischemia and
reperfusion.
- reference: DOI:10.1111/jcmm.15127
reference_title: Mitochondrial and mitochondrial-independent pathways of myocardial cell death during ischaemia and reperfusion injury
supports: SUPPORT
evidence_source: OTHER
snippet: >-
There is also evidence for significant myocardial death by other pathways
such as apoptosis, although this has been challenged.
explanation: >-
This supports apoptotic process as a relevant but not exclusive myocardial
cell-death pathway in infarction.
- reference: DOI:10.1111/jcmm.15127
reference_title: Mitochondrial and mitochondrial-independent pathways of myocardial cell death during ischaemia and reperfusion injury
supports: SUPPORT
evidence_source: OTHER
snippet: >-
Necrosis is known to play a major role in myocardial IR injury.
explanation: >-
This supports necrosis as a major mode of myocardial injury during
ischemia-reperfusion.
- reference: DOI:10.1111/jcmm.15127
reference_title: Mitochondrial and mitochondrial-independent pathways of myocardial cell death during ischaemia and reperfusion injury
supports: SUPPORT
evidence_source: OTHER
snippet: >-
Mitochondria play a central role in both of these pathways of cell death,
as either a causal mechanism is the case of mitochondrial permeability
transition leading to necrosis, or as part of the signalling pathway in
mitochondrial cytochrome c release and apoptosis.
explanation: >-
This supports mitochondrial permeability transition and cytochrome-c
signaling as central mechanisms for necrotic and apoptotic myocardial cell
death.
- name: Posterior electrocardiographic injury pattern
description: >-
Posterior-wall injury may be underdetected on standard 12-lead ECG because
the posterior wall is not directly sampled. Reciprocal anterior ST-segment
depression, especially maximal in V1-V4, and direct posterior-lead ST
elevation identify posterior or posterolateral occlusion MI patterns that
may not satisfy classic STEMI criteria.
locations:
- preferred_term: posterior left ventricular myocardium
term:
id: UBERON:0002349
label: myocardium
downstream:
- target: Delayed reperfusion risk
description: >-
Failure to recognize STEMI-negative occlusion MI patterns delays urgent
catheterization and reperfusion despite similar PCI needs.
evidence:
- reference: DOI:10.3390/jcm13175201
reference_title: "OMI/NOMI: Time for a New Classification of Acute Myocardial Infarction"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Forty percent of patients with acute coronary occlusion myocardial
infarction (OMI) do not present with STEMI criteria, which delays their
treatment and increases morbidity and mortality.
explanation: >-
This supports the broader occlusion-MI framing for posterior MI patterns
that may not meet STEMI thresholds.
phenotypes:
- category: Cardiovascular
name: Posterior-lead ST-segment elevation
diagnostic: true
description: >-
ST-segment elevation can be visible in posterior leads V7-V9 even when the
standard 12-lead ECG lacks classic anterior ST elevation.
phenotype_term:
preferred_term: posterior-lead ST segment elevation
temporality: ACUTE
term:
id: HP:0012251
label: ST segment elevation
evidence:
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
three cases of acute myocardial infarction presenting as isolated
ST-segment elevation in the posterior leads (V7–V9)
explanation: >-
This supports posterior-lead ST elevation as a diagnostic
electrocardiographic manifestation.
- category: Cardiovascular
name: Anterior precordial ST-segment depression
diagnostic: true
description: >-
Reciprocal ST-segment depression in V1-V3 or V1-V4 is a key standard
12-lead clue to posterior or posterolateral occlusion MI.
phenotype_term:
preferred_term: anterior precordial ST segment depression
temporality: ACUTE
term:
id: HP:0012250
label: ST segment depression
evidence:
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
who presented with ST-segment depression in V1–V3 that resolved gradually.
explanation: >-
This posterior-MI case series supports V1-V3 ST-segment depression as a
recurring standard-ECG manifestation.
- category: Cardiovascular
name: Dominant anterior R wave
diagnostic: true
description: >-
A tall or dominant R wave, especially with R/S ratio greater than 1 in early
precordial leads, can be a mirror-image ECG sign of acute posterior wall
myocardial infarction.
phenotype_term:
preferred_term: dominant anterior R wave
temporality: ACUTE
evidence:
- reference: DOI:10.1111/j.1540-8159.1989.tb01844.x
reference_title: "The Tall R Wave in Lead V<sub>1</sub> in Posterior Myocardial Infarction: A Reciprocal Sign or a His‐Purkinje Conduction Disturbance?"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
The significance of the tall R wave in lead V1 with an R/S ratio 1 in
posterior myocardial infarction (PMI) was investigated in 28 patients
during programmed electrical stimulation.
explanation: >-
This human clinical electrophysiology study supports tall R wave with an
elevated R/S ratio as a posterior MI-associated ECG finding.
- category: Cardiovascular
name: Chest pain
diagnostic: false
description: >-
Posterior MI presents in the acute coronary syndrome context, and chest pain
may be the clinical context in which subtle posterior ECG signs are
evaluated.
phenotype_term:
preferred_term: Chest pain
temporality: ACUTE
term:
id: HP:0100749
label: Chest pain
evidence:
- reference: DOI:10.1097/HPC.0000000000000163
reference_title: "Symptoms Predictive of Acute Myocardial Infarction in the Troponin Era: Analysis From the TRAPID-AMI Study"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Symptoms including pulling chest pain, supramammillary right location, and
right arm/shoulder radiation were significantly more likely to occur in
patients with larger AMIs.
explanation: >-
This multicenter acute myocardial infarction substudy supports chest pain
as a relevant acute MI symptom phenotype.
- category: Laboratory
name: Elevated cardiac troponin
diagnostic: true
description: >-
Elevated cardiac troponin supports myocardial injury in acute occlusion MI
definitions and helps distinguish infarction from isolated ECG mimics.
phenotype_term:
preferred_term: elevated cardiac troponin
temporality: ACUTE
evidence:
- reference: DOI:10.3390/jcm13175201
reference_title: "OMI/NOMI: Time for a New Classification of Acute Myocardial Infarction"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
OMI was defined as an acute culprit lesion with TIMI 0–2 flow, or an
acute culprit lesion with TIMI 3 flow intervened upon and with highly
elevated troponin (cTnI > 10.0 ng/mL, hs-cTnI > 5000 ng/L)
explanation: >-
This supports elevated troponin as part of the clinical definition used
for selected acute occlusion MI cases.
diagnosis:
- name: 15-lead electrocardiography with posterior leads
description: >-
Standard 12-lead ECG should be supplemented with posterior leads V7-V9 when
posterior MI is suspected from subtle anterior reciprocal changes or
nondiagnostic STEMI criteria.
diagnosis_term:
preferred_term: electrocardiography
term:
id: MAXO:0000900
label: electrocardiography
results: >-
ST-segment elevation in posterior leads V7-V9 supports posterior myocardial
infarction and helps triage urgent reperfusion.
evidence:
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Routine and accurate interpretations of 15-lead electrocardiography
(12-lead with additional V7–V9) resulted in a better sensitivity for
isolated posterior myocardial infarction diagnoses, followed by a timely
and opportune primary percutaneous coronary intervention.
explanation: >-
This supports routine posterior-lead ECG acquisition and interpretation
for posterior MI diagnosis and timely PCI triage.
- reference: DOI:10.3390/s24185947
reference_title: Clinical Utility of Synthesized 18-Lead Electrocardiography
supports: SUPPORT
evidence_source: OTHER
snippet: >-
ST elevation in leads V7–V9 has the effect of reducing missed acute
coronary syndromes in the posterior wall.
explanation: >-
This review supports posterior leads V7-V9 as a way to reduce missed
posterior-wall ACS.
- name: Coronary angiography for culprit occlusion
description: >-
Coronary angiography identifies total or critical occlusion of
posterior-wall supplying arteries, especially the left circumflex artery and
sometimes the right coronary artery depending on coronary dominance and
infarct anatomy.
diagnosis_term:
preferred_term: X-ray coronary angiography procedure
term:
id: MAXO:0001319
label: X-ray coronary angiography procedure
results: >-
Total or critical occlusion of a posterior-wall culprit artery supports
posterior myocardial infarction and triages immediate revascularization.
evidence:
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Coronary angiography revealed a total/critical occlusion of the proximal
circumflex coronary artery in all three cases.
explanation: >-
This posterior-MI case series supports coronary angiography as the test
that confirms the proximal circumflex culprit occlusion.
- reference: DOI:10.1093/ehjqcco/qcad027
reference_title: "Occlusion of the infarct-related coronary artery presenting as acute coronary syndrome with and without ST-elevation: impact of inflammation and outcomes in a real-world prospective cohort"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
In NSTE-ACS, both LCx and RCA involvement was associated with TCO at
angiography despite the absence of ST-segment elevation.
explanation: >-
This supports LCx and RCA total coronary occlusion as hidden
non-ST-elevation acute coronary syndrome patterns relevant to posterior
infarction.
- name: AI-assisted ECG detection of occlusion MI
description: >-
AI-assisted ECG interpretation is an emerging diagnostic adjunct for
detecting acute occlusion MI on standard 12-lead ECGs; it should be treated
as implementation-dependent decision support rather than a substitute for
clinical judgment or angiographic confirmation.
diagnosis_term:
preferred_term: electrocardiography
term:
id: MAXO:0000900
label: electrocardiography
results: AI models may increase sensitivity for acute occlusion MI compared with STEMI criteria.
evidence:
- reference: DOI:10.1093/ehjdh/ztad074
reference_title: International evaluation of an artificial intelligence-powered electrocardiogram model detecting acute coronary occlusion myocardial infarction
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
The present novel ECG AI model demonstrates superior accuracy to detect
acute OMI when compared with STEMI criteria.
explanation: >-
This supports AI-assisted ECG interpretation as a human-clinical evaluated
diagnostic adjunct for acute occlusion MI detection.
treatments:
- name: Primary percutaneous coronary intervention
description: >-
When posterior MI reflects acute coronary occlusion, timely primary PCI is
the key reperfusion intervention. Posterior-lead ECG and OMI recognition are
important because STEMI-negative occlusion patterns can otherwise experience
delayed catheterization despite similar angiographic PCI needs.
treatment_term:
preferred_term: percutaneous coronary intervention
term:
id: NCIT:C99521
label: Percutaneous Coronary Intervention
target_mechanisms:
- target: Coronary thrombosis and occlusion
treatment_effect: RESTORES
description: >-
PCI mechanically revascularizes the occluded culprit coronary artery,
restoring flow to threatened posterior myocardium.
evidence:
- reference: DOI:10.1186/s13256-022-03570-w
reference_title: "Isolated posterior ST-elevation myocardial infarction: the necessity of routine 15-lead electrocardiography: a case series"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
Routine and accurate interpretations of 15-lead electrocardiography
(12-lead with additional V7–V9) resulted in a better sensitivity for
isolated posterior myocardial infarction diagnoses, followed by a timely
and opportune primary percutaneous coronary intervention.
explanation: >-
This directly links posterior-lead diagnosis to timely primary PCI in
isolated posterior MI.
- reference: DOI:10.3390/jcm13175201
reference_title: "OMI/NOMI: Time for a New Classification of Acute Myocardial Infarction"
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: >-
STEMI(−)OMI patients had significant delays in catheterization, yet had
angiographic findings, rates of PCI, and complications similar to
STEMI(+)OMI.
explanation: >-
This supports urgent PCI-oriented care for occlusion MI even when classic
STEMI criteria are absent.
notes: >-
Posterior myocardial infarction is curated here as a regional and diagnostic
presentation of myocardial infarction, not as a separate monogenic disorder.
Mechanism evidence therefore combines posterior-MI-specific ECG/angiography
literature with broader acute coronary syndrome and myocardial infarction
mechanism literature. No posterior-MI-specific animal model, inherited
variant, or posterior-wall-specific prevention evidence was identified in the
Falcon report; ontology bindings were used only when verified locally with
OAK, so elevated troponin and dominant anterior R-wave findings are recorded
as preferred-term-only phenotypes.
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Posterior myocardial infarction (posterior MI) refers to acute myocardial infarction involving the posterior left ventricular wall. It is frequently under-recognized because the standard 12-lead ECG does not directly visualize the posterior wall; instead, posterior injury often appears as reciprocal (“mirror-image”) changes in the anterior precordial leads (V1–V3). Confirmation and improved detection can be achieved by recording posterior leads V7–V9, where small ST-elevation thresholds (≥0.5 mm) are clinically important. Contemporary research emphasizes that a substantial portion of acute coronary occlusions (including many circumflex/posterior occlusions) do not meet classic STEMI criteria and may benefit from an “occlusion MI (OMI)” paradigm and/or AI-assisted ECG interpretation. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3, kola2024ominomitimefor pages 2-4, herman2024internationalevaluationof pages 1-2)
Posterior MI is an acute MI affecting the posterior LV wall, often missed on 12-lead ECG because posterior injury is not directly sampled by standard leads; clinicians rely on reciprocal anterior changes and/or posterior leads V7–V9 to detect posterior ST-elevation patterns. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3)
The retrieved evidence did not include OMIM, Orphanet, MeSH, or MONDO identifiers specific to posterior MI; therefore, these identifiers cannot be confirmed from the retrieved sources. (garciaarias2024isolatedposterioracute pages 1-3, kwok2024structuralcomplicationsfollowing pages 2-4)
ICD-10 coding for acute MI is represented within the I21.* family in administrative datasets; one large US inpatient study identified STEMI admissions using ICD-10 codes I21.0, I21.1, I21.2, and I21.3, illustrating how MI subtypes are operationalized in claims/inpatient datasets (note: this evidence does not establish that I21.2 is posterior-MI-specific). (kwok2024structuralcomplicationsfollowing pages 2-4)
Commonly used labels in the retrieved literature include: “posterior myocardial infarction,” “posterior MI,” “posterior STEMI,” “posterior wall MI,” and “isolated posterior MI.” (garciaarias2024isolatedposterioracute pages 1-3, alsagaff2022isolatedposteriorstelevation pages 8-8)
Evidence here is largely aggregated disease-level clinical literature (ECG-focused reviews/case series and OMI-paradigm papers) plus administrative dataset usage of ICD-10 codes in inpatient research. (garciaarias2024isolatedposterioracute pages 1-3, kwok2024structuralcomplicationsfollowing pages 2-4)
| Category | Field | Value | Notes / Resource Type |
|---|---|---|---|
| Disease concept | Brief definition | Posterior myocardial infarction (PMI) is an acute myocardial infarction involving the posterior left ventricular wall, often under-recognized on standard 12-lead ECG because the posterior wall is not directly visualized; posterior leads V7-V9 and reciprocal/anterior mirror changes aid diagnosis. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3) | Primarily disease-level clinical/guideline-style characterization from case series/reviews; not a unique EHR-only construct. |
| Synonyms | Common names | posterior myocardial infarction; posterior MI; posterior STEMI; isolated posterior MI; posterior wall MI. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3, alsagaff2022isolatedposteriorstelevation pages 8-8) | Synonym usage derived from clinical literature and ECG-focused reports/guidance. |
| Standard identifiers | ICD-10 family | Acute myocardial infarction is coded under ICD-10 I21. / I22. in claims/EHR validation studies. (kwok2024structuralcomplicationsfollowing pages 2-4) | EHR/claims-oriented coding framework; used for case identification in administrative datasets. |
| Standard identifiers | ICD-10 STEMI subtype example | I21.2 was explicitly included among STEMI ICD-10 codes (I21.0, I21.1, I21.2, I21.3) in a National Inpatient Sample STEMI outcomes study. (kwok2024structuralcomplicationsfollowing pages 2-4) | Administrative/research coding use; evidence supports relevance to STEMI datasets, but retrieved sources do not prove it is posterior-MI-specific. |
| Standard identifiers | MONDO ID | not found in retrieved sources | No MONDO identifier was present in the retrieved evidence. |
| Standard identifiers | MeSH | not found in retrieved sources | No MeSH identifier was present in the retrieved evidence. |
| Resource provenance | Disease-level vs patient-level information | Retrieved PMI information is mostly aggregated disease-level clinical literature/guideline-style evidence; ICD-10 usage comes from EHR/claims and inpatient database studies, while ECG criteria come from guideline/review/case-series literature. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3, kwok2024structuralcomplicationsfollowing pages 2-4) | Mixed provenance: disease-level clinical resources plus patient-level coding/administrative datasets. |
| Coding caution | Specificity of coding for PMI | Retrieved evidence supports AMI/STEMI family coding (I21.*) and inclusion of I21.2 in STEMI analyses, but does not provide a posterior-MI-specific code mapping from an authoritative coding manual. (kwok2024structuralcomplicationsfollowing pages 2-4) | Important for knowledge-base curation: coding evidence here is indirect for PMI localization. |
Table: This table summarizes how posterior myocardial infarction is defined, named, and represented in the retrieved evidence. It distinguishes disease-level ECG/guideline terminology from ICD-10 coding used in EHR/claims and inpatient database research.
Posterior MI is generally caused by acute reduction/cessation of coronary blood flow due to atherosclerotic plaque rupture/erosion with superimposed thrombosis (type 1 MI framework). (młynarska2024fromatheroscleroticplaque pages 1-3, młynarska2024fromatheroscleroticplaque pages 4-6)
In posterior/inferior territories, the culprit vessel is frequently the left circumflex (LCx) or right coronary artery (RCA), and posterior MI may present without classic ST-elevation criteria. (garciaarias2024isolatedposterioracute pages 1-3, bruno2023occlusionofthe pages 2-3)
A 2024 molecular review summarizing type 1 MI pathogenesis lists major predisposing factors including high LDL-C, cigarette smoking, chronic kidney disease, diabetes mellitus, hypertension, obesity/adiposity, and familial hypercholesterolaemia (FH). (młynarska2024fromatheroscleroticplaque pages 1-3)
Genetic susceptibility (example: FH): FH is described as autosomal dominant and linked to high LDL-C, with implicated genes including LDLR, APOB, and PCSK9. (młynarska2024fromatheroscleroticplaque pages 3-4)
The retrieved evidence does not provide quantified protective factors (e.g., effect sizes for statins, smoking cessation, exercise) specific to posterior MI or MI generally. This is a limitation of the current retrieved corpus. (młynarska2024fromatheroscleroticplaque pages 1-3)
No gene–environment interaction data specific to posterior MI was present in the retrieved sources. (młynarska2024fromatheroscleroticplaque pages 3-4)
Posterior MI presents as an acute coronary syndrome; because posterior wall injury is “electrically hidden” on standard ECG, presentation is often defined by ECG patterns and biomarker/imaging confirmation rather than unique symptomatology in the retrieved sources. (garciaarias2024isolatedposterioracute pages 1-3)
Posterior MI often produces reciprocal changes in V1–V3 rather than anterior ST elevation. Key patterns include: - Horizontal ST depression in V1–V3 (often maximal in early precordial leads). (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3) - Dominant/tall R waves with R/S ratio >1 (often V2–V4), sometimes with broad R waves (>30 ms). (moskovitz2025aninterestingcase pages 2-3) - Upright T waves in anterior leads accompanying ST depression. (moskovitz2025aninterestingcase pages 2-3)
Posterior lead confirmation: ST-elevation ≥0.5 mm in V7–V9 is described as a confirmatory threshold. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3)
In the OMI definition used in a 2024 OMI/NOMI reclassification study, markedly elevated troponin thresholds were part of the operational definition for certain angiographic cases (e.g., cTnI >10.0 ng/mL or hs-cTnI >5000 ng/L when TIMI 3 flow lesions were intervened upon). (kola2024ominomitimefor pages 2-4)
These ontology suggestions are provided for knowledge-base structuring; the retrieved sources do not explicitly enumerate ontology IDs. - HPO (symptoms/signs): Chest pain (HP:0100749), ST segment depression (HP:0025315), ST segment elevation (HP:0025320), Elevated cardiac troponin (HP:0030343). - LOINC (lab): high-sensitivity cardiac troponin assays (LOINC varies by platform).
Posterior MI is not a monogenic disease; it is typically multifactorial, with genetic contributions largely mediated through atherosclerotic risk (e.g., FH). (młynarska2024fromatheroscleroticplaque pages 3-4, młynarska2024fromatheroscleroticplaque pages 1-3)
No “causal gene” for posterior MI was identified in the retrieved evidence; however, genes implicated in familial hypercholesterolaemia (a major MI risk state) include LDLR, APOB, and PCSK9. (młynarska2024fromatheroscleroticplaque pages 3-4)
The retrieved evidence does not provide variant-level nomenclature, allele frequencies (gnomAD), or ACMG classifications for posterior MI. (młynarska2024fromatheroscleroticplaque pages 3-4)
Not found in retrieved sources for posterior MI. (młynarska2024fromatheroscleroticplaque pages 1-3)
The retrieved 2024 type 1 MI review identifies major lifestyle/environmental contributors to atherosclerotic MI risk including cigarette smoking, diet/physical inactivity (via obesity/adiposity), and metabolic risk factors (hypertension, diabetes). No posterior-wall-specific environmental risks were identified. (młynarska2024fromatheroscleroticplaque pages 1-3, młynarska2024fromatheroscleroticplaque pages 17-19)
In a large prospective cohort, LCx occlusion in NSTE-ACS was associated with higher 1-year MACE, and inflammatory markers (hs-CRP, leukocyte indices) were associated with total coronary occlusion in NSTE-ACS, supporting systemic inflammation as a correlating feature of higher-risk occlusion phenotypes. (bruno2023occlusionofthe pages 2-3)
Ischemia and necrosis affect cardiomyocytes and the microvasculature; upstream mechanisms involve vascular endothelium, inflammatory cells, and platelets in thrombosis. (młynarska2024fromatheroscleroticplaque pages 4-6)
Posterior MI is an acute presentation within ACS. A critical temporal feature is the diagnostic delay when patients do not meet classic STEMI criteria, leading to later catheterization/reperfusion for occlusive infarctions that are STEMI-negative. (kola2024ominomitimefor pages 2-4, herman2024internationalevaluationof pages 7-8)
Posterior MI is commonly suspected based on 12-lead ECG reciprocal patterns and confirmed with posterior leads.
Key practical criteria and quantitative thresholds are summarized here: - Posterior lead criterion: ST-elevation ≥0.5 mm in V7–V9 is described as confirmatory. (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3) - Mirror-image 12-lead pattern: horizontal ST depression V1–V3 with dominant R waves (R/S >1) and upright T waves. (moskovitz2025aninterestingcase pages 2-3) - High-specificity marker: “suspected ischemic” ST depression maximal in V1–V4 had 97% specificity and 37% sensitivity for OMI in a high-risk ACS cohort (a posterior/lateral-occlusion enrichment pattern). (meyers2021ischemicst‐segmentdepression pages 13-14)
One cited dataset noted that only ~53% of circumflex-related posterior MI showed ≥1.0 mm posterior-lead ST elevation, while lowering the ST-elevation threshold to 0.5 mm increased detection to 94% (with ~6% still missed). (ramjaun2021ecgchangesin pages 3-4)
A 2024 Sensors review describes synthesized 18-lead ECG (syn18-ECG) that computationally derives posterior leads V7–V9 from a standard 12-lead recording, avoiding patient repositioning and additional electrode placement; ST elevation in V7–V9 is highlighted as a mechanism to reduce missed posterior ACS. (yamamoto2024clinicalutilityof pages 1-3, yamamoto2024clinicalutilityof pages 3-4)
Lead placement visualization: posterior electrode placement for V7–V9 (useful for protocol implementation) is shown in the extracted figure. (yamamoto2024clinicalutilityof media 15a08389)
Expert/opinion-driven and data-supported analysis: - A 2024 reclassification study found that 40% of angiographic OMI did not fulfill STEMI criteria and that STEMI-negative OMI was associated with major PCI delays (only 11% within 12 h vs 77% for STEMI-positive OMI). (kola2024ominomitimefor pages 2-4) - A 2024 international evaluation of an AI ECG model reported markedly higher sensitivity for detecting OMI than STEMI criteria (80.6% vs 32.5%) with high specificity (93.7%). (herman2024internationalevaluationof pages 1-2) - In that AI study, STEMI criteria missed 67.5% of OMI patients; only 33.9% of those missed received revascularization within 2 hours, illustrating time-sensitive consequences of STEMI-only activation logic. (herman2024internationalevaluationof pages 7-8)
| Finding/criterion | Quantitative threshold or statistic | Clinical implication | Source |
|---|---|---|---|
| 12-lead ECG “mirror” signs of posterior MI/posterior OMI | Horizontal ST depression in V1-V3; dominant/tall R wave with R/S >1 (often V2-V4); upright anterior T waves; broad R wave >30 ms | Standard 12-lead ECG may show reciprocal posterior-wall ischemia rather than classic ST elevation; should prompt suspicion for posterior MI and consideration of posterior leads or urgent angiography | (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3, moskovitz2025aninterestingcase pages 3-3) |
| Posterior leads V7-V9 diagnostic threshold | ST-segment elevation >=0.5 mm in V7-V9 | Confirms posterior infarction pattern that may be missed on standard 12-lead ECG; supports emergent reperfusion pathway as STEMI-equivalent/OMI pattern | (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3) |
| ST depression maximal in V1-V4 (STDmaxV1-4) | Specificity 97%; sensitivity 37% for OMI; 90% of patients with suspected ischemic STDmaxV1-4 had an acute culprit lesion, 84% had OMI | Highly specific but not sensitive marker; useful for recognizing posterior/lateral occlusion MI, especially circumflex-related events that fail STEMI criteria | (meyers2021ischemicst‐segmentdepression pages 13-14) |
| Lowering posterior lead threshold from 1.0 mm to 0.5 mm | Detection increased from ~53% to 94% | Supports the modern lower V7-V9 STE cutoff because many posterior infarctions have only small-amplitude STE in posterior leads | (ramjaun2021ecgchangesin pages 3-4) |
| Incidence/prevalence: isolated posterior MI | ~3.3%; ~4%; 3-7% of acute MIs/ACS presentations depending on series | Isolated posterior MI is uncommon and therefore frequently under-recognized, contributing to delayed diagnosis | (garciaarias2024isolatedposterioracute pages 1-3, moskovitz2025aninterestingcase pages 2-3) |
| Posterior involvement with other infarct territories | Posterior involvement occurs in ~20% of lateral or inferior infarctions | Posterior extension is not rare in inferior/lateral MI and should be actively sought with posterior leads when anterior ST depression is present | (garciaarias2024isolatedposterioracute pages 1-3) |
| OMI paradigm misclassification (Kola 2024) | 98/334 ACS patients (29.3%) were STEMI(-)OMI; 96/241 OMI patients (40%) did not fulfill STEMI criteria; only 11% of STEMI(-)OMI underwent PCI within 12 h vs 77% of STEMI(+)OMI | Reliance on STEMI criteria misses a substantial fraction of occlusive infarctions and is associated with major reperfusion delay | (kola2024ominomitimefor pages 2-4) |
| AI/OMI triage performance vs STEMI criteria (Herman 2024) | AI AUC 0.938, sensitivity 80.6%, specificity 93.7% vs STEMI criteria sensitivity 32.5%, specificity 97.7%; OMI prevalence 21.6% in test set | AI-enhanced ECG interpretation can improve detection of occult occlusion MI, including posterior/inferior territory occlusions that do not meet STEMI criteria | (herman2024internationalevaluationof pages 2-3, herman2024internationalevaluationof pages 1-2, herman2024internationalevaluationof pages 7-8) |
| OMI delays and false negatives on STEMI criteria (Herman 2024) | STEMI criteria missed 330 OMI patients (67.5% of all OMI); only 112/330 (33.9%) received revascularization <2 h; AI identified 133/218 STEMI-criteria false-negative OMI patients (61.0%) on first ECG | Highlights real-world treatment delay caused by STEMI-based classification and the potential benefit of OMI-focused or AI-supported recognition pathways | (herman2024internationalevaluationof pages 7-8) |
Table: This table summarizes the main electrocardiographic criteria and high-yield quantitative statistics for posterior myocardial infarction/posterior OMI. It is useful for contrasting classic posterior ECG findings with newer OMI-era evidence on missed occlusions and diagnostic delay.
In a prospective real-world cohort (SPUM-ACS), among NSTE-ACS patients, total coronary occlusion was more frequent for LCx (27%) and RCA (24%) than for LAD (9%), and LCx involvement independently predicted higher 1-year MACE (adjusted HR 1.68, 95% CI 1.10–2.59). (bruno2023occlusionofthe pages 2-3)
Evidence from OMI/AI literature indicates that STEMI criteria miss a large fraction of occlusive infarctions, with substantial delays to catheterization/revascularization for those missed, which is mechanistically consistent with worse outcomes in untreated/delayed occlusion states. (kola2024ominomitimefor pages 2-4, herman2024internationalevaluationof pages 7-8)
The retrieved evidence supports that posterior MI patterns represent clinically important occlusion phenotypes where timely reperfusion is critical; however, detailed pharmacotherapy algorithms (dual antiplatelet therapy, anticoagulation, beta-blockers, statins) are not described in the retrieved excerpts. (moskovitz2025aninterestingcase pages 2-3, kola2024ominomitimefor pages 2-4)
In case-based reports, posterior MI due to LCx occlusion was treated with PCI and associated with rapid ECG improvement. (moskovitz2025aninterestingcase pages 3-3)
(These ontology suggestions are not explicitly mapped in the retrieved sources.)
Primary and secondary prevention strategies for atherosclerotic MI are not quantified in the retrieved excerpts; however, the etiologic risk factors enumerated (LDL-C, smoking, hypertension, diabetes, CKD, obesity/FH) imply standard prevention targets in clinical practice. Quantified preventive effect sizes and guideline thresholds were not present in the retrieved evidence and therefore are not asserted here. (młynarska2024fromatheroscleroticplaque pages 1-3)
No comparative veterinary or cross-species posterior MI information was found in retrieved sources. (młynarska2024fromatheroscleroticplaque pages 1-3)
No posterior MI-specific model organism evidence was found in retrieved sources. (młynarska2024fromatheroscleroticplaque pages 1-3)
The extracted image demonstrates posterior electrode placement for V7, V8, and V9 on the left posterior thorax, supporting practical implementation of posterior lead acquisition protocols. (yamamoto2024clinicalutilityof media 15a08389)
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