The standard 12-lead ECG does not directly examine the right ventricle and does a relatively poor job at examining the posterior basal and lateral wall of the left ventricle. 

As a result we often miss acute STEMI in the distribution of the circumflex. ST-depression that is maximal in leads V1-V3 is sometimes erroneously attributed to "anterior ischemia" (a misnomer) and leads I and aVL can be "electrocardiographically silent" (less than 1 mm ST-elevation) which makes reciprocal changes in the inferior leads very important!

The use of additional leads like V4R  and posterior leads V7, V8, and V9 may improve sensitivity for right ventricular and posterior infarction. But be careful! Posterior leads V7, V8, and V9 can be negative and the LCX can still be occluded!

So next time when you are in confusion go for that extra leads!!!!

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