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All ECG 26
The ECG shows sinus rhythm at a rate of about 80 beats per minute (bpm). The QRS is narrow, with a frontal plane axis of 0°. There are Q waves in I and AVL. The R wave is 10 mm (quite tall) in V1, and very small (< 2 mm) in V2-6. These findings are consistent with an extensive postero-lateral ST-elevation myocardial infarction (STEMI).
MI-related ECG changes from the posterior wall are seen in the precordial leads with a configuration opposite of other myocardial segments. Instead of ST segment elevation, a posterior MI is characterized by ST depression in lead V1 and frequently V2, and the R wave is large in lead V1. (Turn the ECG upside down and you will see the equivalent of ST segment elevation in V1 with a large Q wave). For a detailed review, click on the Posterior MI ECG Review link below.
Causes of R>S in lead V1 include posterior MI, right bundle branch block (RBBB), Wolff-Parkinson-White syndrome type A, right ventricular hypertrophy, ventricular tachycardia with a RBBB pattern and isolated posterior wall hypertrophy (Duchenne's muscular dystrophy).
Related: Posterior MI ECG Review