Posterior MI - ECG Indications & Clinical Features

Anatomy & Epidemiology

Posterior MI accounts for 15-20% of all AMIs and usually occurs with inferior or inferolateral infarctions. Isolated posterior MI (showing ST elevation only in posterior leads V7-V9) accounts for ~5% of AMI cases.

Culprit vessels:

Right coronary artery (RCA) or its posterior descending branch
Left circumflex artery (LCx) - nondominant; isolated posterior MI is typically a nondominant LCx occlusion

Note: Cardiac MRI evidence suggests these so-called "posterior" infarctions actually involve the lateral left ventricular wall. A consensus document now recommends reclassifying them as inferobasal MI.

ECG Indications (12-Lead)

Because no standard leads directly face the posterior wall, diagnosis relies on reciprocal (mirror-image) changes in right precordial leads V1-V3:

ECG Finding	Leads	Significance
Horizontal ST depression	V1-V3	Most important sign; mirror of posterior ST elevation
Upright (tall) T wave	V1-V3	Posterior T-wave inversion seen as upright anteriorly
Tall, broad R wave (≥0.04 sec in V1-V2)	V1-V2	Mirror image of posterior Q wave; may be delayed
R/S ratio ≥1 with positive T wave	V1-V2	Suggests prior posterior MI (absent RVH or RBBB)

The combination of horizontal ST depression + upright T wave in V1-V3 increases diagnostic accuracy significantly.

The ECG above shows a classic inferior MI with posterior extension - note the ST depression in V1-V3.

Posterior Leads (V7-V9) - Confirmatory

Extending the ECG with posterior leads V7-V9 increases sensitivity for detecting LCx-related injury:

ST elevation ≥0.5 mm in V7-V9 = direct evidence of posterior wall injury
Leads are placed at the posterior left chest (V7: posterior axillary line, V8: tip of scapula, V9: left paraspinal)
Tintinalli recommends placing V7-V9 specifically when posterior MI is suspected from circumflex lesion

Key Clinical Indications to Suspect Posterior MI

ST depression in V1-V3 without anterior ischemic symptoms - think posterior MI
Inferior STEMI (II, III, aVF) with V1-V3 depression - posterior extension increases infarct size, lowers EF, worsens outcomes
Tall dominant R in V1 without other explanation (no RVH, no RBBB, no WPW)
Isolated LCx territory ischemia - the LCx is "ECG silent" on the standard 12-lead; posterior leads essential

Treatment Implications

Posterior MI qualifies as STEMI equivalent - immediate reperfusion (PCI preferred)
Fibrinolytic therapy is generally contraindicated in ST-depression UNLESS posterior MI is suspected (Washington Manual: fibrinolytics are contraindicated "in patients with ECG evidence of ST-segment depressions, unless posterior MI suspected")
Posterior MI with inferior involvement: order right-sided leads (V4R) simultaneously to rule out RV infarction (affects management - avoid nitrates, preload-dependent state)

Association with Right Ventricular Infarction

Proximal RCA occlusion can cause inferior + posterior + RV infarction simultaneously. In patients with inferior STEMI + posterior extension:

Larger infarct zone, lower ejection fraction
Higher cardiovascular morbidity and mortality than isolated inferior MI
ST elevation in V1 with inferior STEMI + V4R elevation = concomitant RV infarction

Sources: Rosen's Emergency Medicine, p. 1006 | Goldman-Cecil Medicine | Washington Manual of Medical Therapeutics

Create a quick reference guide for posterior MI ECG patterns

Asking for Preferences

Reading File

Running Command

ls /home/daytona/skills/docx/

Running Command

mkdir -p /home/daytona/workspace/posterior-mi-guide && ls /home/daytona/workspace/posterior-mi-guide/

Writing File

~/posterior-mi-guide/create_guide.js

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  AlignmentType, HeadingLevel, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageOrientation, Header, Footer, PageNumber, NumberFormat,
  UnderlineType
} = require('docx');
const fs = require('fs');

// ─── Color Palette ─────────────────────────────────────────────
const RED       = "C0392B";   // danger / alert
const DARK_RED  = "922B21";
const ORANGE    = "E67E22";
const BLUE      = "1A5276";   // header bg
const LIGHT_BLUE= "D6EAF8";   // alt row / highlight
const MID_BLUE  = "2980B9";
const DARK_GREY = "2C3E50";
const MED_GREY  = "5D6D7E";
const LIGHT_GREY= "F2F3F4";
const WHITE     = "FFFFFF";
const YELLOW_HL = "FDFEFE";
const ORANGE_HL = "FEF9E7";
const RED_HL    = "FDEDEC";

// ─── Helper: thick border set ────────────────────────────────────
function solidBorder(color = "000000", sz = 6) {
  return { style: BorderStyle.SINGLE, size: sz, color };
}
function noBorder() {
  return { style: BorderStyle.NONE, size: 0, color: "FFFFFF" };
}

// ─── Helper: shaded table cell ──────────────────────────────────
function cell(paragraphs, { bg = WHITE, bold = false, color = DARK_GREY, width, vAlign = VerticalAlign.CENTER, borders } = {}) {
  return new TableCell({
    children: Array.isArray(paragraphs) ? paragraphs : [paragraphs],
    shading: { type: ShadingType.SOLID, color: bg, fill: bg },
    verticalAlign: vAlign,
    width: width ? { size: width, type: WidthType.PERCENTAGE } : undefined,
    borders: borders || {
      top: solidBorder("CCCCCC", 4),
      bottom: solidBorder("CCCCCC", 4),
      left: solidBorder("CCCCCC", 4),
      right: solidBorder("CCCCCC", 4),
    },
  });
}

// ─── Helper: simple paragraph ───────────────────────────────────
function para(text, { bold = false, color = DARK_GREY, size = 20, align = AlignmentType.LEFT, italic = false, spacing = {} } = {}) {
  return new Paragraph({
    alignment: align,
    spacing: { before: 60, after: 60, ...spacing },
    children: [new TextRun({ text, bold, color, size, italics: italic, font: "Calibri" })],
  });
}

function bulletPara(text, { bold = false, color = DARK_GREY, size = 20 } = {}) {
  return new Paragraph({
    bullet: { level: 0 },
    spacing: { before: 30, after: 30 },
    children: [new TextRun({ text, bold, color, size, font: "Calibri" })],
  });
}

// ─── Helper: header row ─────────────────────────────────────────
function headerRow(texts, widths = []) {
  return new TableRow({
    tableHeader: true,
    children: texts.map((t, i) =>
      cell(
        para(t, { bold: true, color: WHITE, size: 19, align: AlignmentType.CENTER }),
        { bg: BLUE, width: widths[i] || undefined, borders: { top: solidBorder(BLUE, 6), bottom: solidBorder(BLUE, 6), left: solidBorder(BLUE, 6), right: solidBorder(BLUE, 6) } }
      )
    ),
  });
}

// ─── SECTION HEADING ────────────────────────────────────────────
function sectionHeading(text, color = BLUE) {
  return new Paragraph({
    spacing: { before: 200, after: 80 },
    border: { bottom: { style: BorderStyle.SINGLE, size: 8, color } },
    children: [
      new TextRun({ text: text.toUpperCase(), bold: true, color, size: 26, font: "Calibri", allCaps: true }),
    ],
  });
}

// ─── ALERT BOX (shaded paragraph) ──────────────────────────────
function alertBox(label, text, bgColor = RED_HL, labelColor = RED) {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({
        children: [
          cell(
            [
              new Paragraph({
                spacing: { before: 40, after: 40 },
                children: [
                  new TextRun({ text: label + " ", bold: true, color: labelColor, size: 20, font: "Calibri" }),
                  new TextRun({ text, color: DARK_GREY, size: 20, font: "Calibri" }),
                ],
              }),
            ],
            { bg: bgColor, borders: { top: solidBorder(labelColor, 10), bottom: solidBorder(labelColor, 10), left: solidBorder(labelColor, 20), right: solidBorder(labelColor, 10) } }
          ),
        ],
      }),
    ],
  });
}

// ═══════════════════════════════════════════════════════════════
//  DOCUMENT BUILD
// ═══════════════════════════════════════════════════════════════

const doc = new Document({
  creator: "Orris Medical AI",
  title: "Posterior MI – ECG Quick Reference Guide",
  description: "Clinical quick reference for ECG diagnosis and management of Posterior Myocardial Infarction",
  styles: {
    default: {
      document: {
        run: { font: "Calibri", size: 20, color: DARK_GREY },
      },
    },
  },
  sections: [
    {
      properties: {
        page: {
          margin: { top: 720, bottom: 720, left: 900, right: 900 },
        },
      },
      headers: {
        default: new Header({
          children: [
            new Table({
              width: { size: 100, type: WidthType.PERCENTAGE },
              rows: [
                new TableRow({
                  children: [
                    cell(
                      para("POSTERIOR MI — ECG QUICK REFERENCE GUIDE", { bold: true, color: WHITE, size: 22, align: AlignmentType.LEFT }),
                      { bg: BLUE, borders: { top: noBorder(), bottom: noBorder(), left: noBorder(), right: noBorder() } }
                    ),
                    cell(
                      para("Emergency Cardiology", { color: LIGHT_BLUE, size: 18, align: AlignmentType.RIGHT }),
                      { bg: BLUE, borders: { top: noBorder(), bottom: noBorder(), left: noBorder(), right: noBorder() } }
                    ),
                  ],
                }),
              ],
            }),
          ],
        }),
      },
      footers: {
        default: new Footer({
          children: [
            new Paragraph({
              alignment: AlignmentType.CENTER,
              children: [
                new TextRun({ text: "Sources: Rosen's Emergency Medicine | Goldman-Cecil Medicine | Washington Manual  |  Page ", color: MED_GREY, size: 16, font: "Calibri" }),
                new TextRun({ children: [PageNumber.CURRENT], color: MED_GREY, size: 16, font: "Calibri" }),
              ],
            }),
          ],
        }),
      },
      children: [

        // ── TITLE BLOCK ──────────────────────────────────────────
        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            new TableRow({
              children: [
                cell(
                  [
                    new Paragraph({
                      alignment: AlignmentType.CENTER,
                      spacing: { before: 80, after: 20 },
                      children: [new TextRun({ text: "POSTERIOR MI", bold: true, color: WHITE, size: 48, font: "Calibri" })],
                    }),
                    new Paragraph({
                      alignment: AlignmentType.CENTER,
                      spacing: { before: 0, after: 80 },
                      children: [new TextRun({ text: "ECG Pattern Recognition & Management", color: LIGHT_BLUE, size: 24, font: "Calibri", italics: true })],
                    }),
                  ],
                  {
                    bg: BLUE,
                    borders: { top: noBorder(), bottom: noBorder(), left: noBorder(), right: noBorder() },
                  }
                ),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ── EPIDEMIOLOGY CALLOUT ──────────────────────────────────
        alertBox(
          "Key Facts:",
          "Posterior MI = 15–20% of all AMIs. Isolated posterior MI ~5%. Usually accompanies inferior or inferolateral MI. Reclassified as \"Inferobasal MI\" by consensus. Culprits: RCA, posterior descending branch, or left circumflex (LCx).",
          LIGHT_BLUE,
          MID_BLUE
        ),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 1 — 12-LEAD ECG FINDINGS
        // ══════════════════════════════════════════════════════════
        sectionHeading("1. 12-Lead ECG Findings (Reciprocal Changes in V1–V3)"),

        para(
          "No standard leads face the posterior wall — diagnosis relies on mirror-image (reciprocal) changes in right precordial leads V1–V3:",
          { size: 20, color: MED_GREY, spacing: { before: 60, after: 100 } }
        ),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            headerRow(["ECG Finding", "Leads", "Mechanism / Notes"], [40, 20, 40]),
            new TableRow({
              children: [
                cell(para("Horizontal ST-segment depression", { bold: true, color: RED, size: 20 }), { bg: RED_HL, width: 40 }),
                cell(para("V1–V3", { align: AlignmentType.CENTER, size: 20 }), { bg: RED_HL, width: 20 }),
                cell(para("Most important sign. Mirror image of posterior ST elevation. Fibrinolytics INDICATED here (exception to ST-depression rule).", { size: 19 }), { bg: RED_HL, width: 40 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("Tall, broad R wave (≥0.04 sec)", { bold: true, color: DARK_RED, size: 20 }), { bg: LIGHT_GREY, width: 40 }),
                cell(para("V1–V2", { align: AlignmentType.CENTER, size: 20 }), { bg: LIGHT_GREY, width: 20 }),
                cell(para("Mirror image of posterior Q wave. Emergence may be delayed. R/S ratio ≥1 with positive T suggests prior posterior MI.", { size: 19 }), { bg: LIGHT_GREY, width: 40 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("Upright (tall) T wave", { bold: true, color: ORANGE, size: 20 }), { bg: ORANGE_HL, width: 40 }),
                cell(para("V1–V3", { align: AlignmentType.CENTER, size: 20 }), { bg: ORANGE_HL, width: 20 }),
                cell(para("Mirror of posterior T-wave inversion. Combined with horizontal ST depression = high diagnostic accuracy.", { size: 19 }), { bg: ORANGE_HL, width: 40 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("R/S ratio ≥ 1 + positive T", { bold: true, color: MID_BLUE, size: 20 }), { bg: LIGHT_GREY, width: 40 }),
                cell(para("V1–V2", { align: AlignmentType.CENTER, size: 20 }), { bg: LIGHT_GREY, width: 20 }),
                cell(para("Suggests prior posterior MI — only if RVH and RBBB are absent. Must correlate clinically.", { size: 19 }), { bg: LIGHT_GREY, width: 40 }),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 40, after: 0 }, children: [] }),
        alertBox(
          "Diagnostic Tip:",
          "Horizontal ST depression + upright T wave in V1–V3 together = highest diagnostic accuracy for acute posterior MI on 12-lead ECG.",
          "#EAF4FB",
          MID_BLUE
        ),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 2 — POSTERIOR LEADS V7–V9
        // ══════════════════════════════════════════════════════════
        sectionHeading("2. Posterior Leads V7–V9 (Confirmatory)"),

        para("Place posterior leads whenever posterior MI is suspected on the standard 12-lead:", { size: 20, color: MED_GREY, spacing: { before: 60, after: 100 } }),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            headerRow(["Lead", "Placement", "Finding", "Interpretation"], [12, 35, 28, 25]),
            new TableRow({
              children: [
                cell(para("V7", { bold: true, align: AlignmentType.CENTER, size: 20 }), { bg: LIGHT_GREY }),
                cell(para("Left posterior axillary line, same horizontal level as V6", { size: 19 }), { bg: LIGHT_GREY }),
                cell(para("ST elevation ≥ 0.5 mm", { bold: true, color: RED, size: 19 }), { bg: LIGHT_GREY }),
                cell(para("Direct posterior injury", { size: 19 }), { bg: LIGHT_GREY }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("V8", { bold: true, align: AlignmentType.CENTER, size: 20 }), { bg: WHITE }),
                cell(para("Tip of the left scapula, same horizontal level", { size: 19 }), { bg: WHITE }),
                cell(para("ST elevation ≥ 0.5 mm", { bold: true, color: RED, size: 19 }), { bg: WHITE }),
                cell(para("Confirms LCx occlusion territory", { size: 19 }), { bg: WHITE }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("V9", { bold: true, align: AlignmentType.CENTER, size: 20 }), { bg: LIGHT_GREY }),
                cell(para("Left paraspinal region, same horizontal level", { size: 19 }), { bg: LIGHT_GREY }),
                cell(para("ST elevation ≥ 0.5 mm", { bold: true, color: RED, size: 19 }), { bg: LIGHT_GREY }),
                cell(para("Highest specificity for posterior MI", { size: 19 }), { bg: LIGHT_GREY }),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 40, after: 0 }, children: [] }),
        alertBox(
          "Clinical Indication:",
          "Obtain V7–V9 in ANY patient with inferior STEMI or unexplained ST depression in V1–V3. ST elevation ≥0.5 mm in ≥1 posterior lead = STEMI equivalent → activate cath lab.",
          RED_HL,
          RED
        ),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 3 — CULPRIT VESSEL & ASSOCIATED INFARCTS
        // ══════════════════════════════════════════════════════════
        sectionHeading("3. Culprit Vessel Patterns"),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            headerRow(["Vessel", "Territory", "Associated Infarcts", "ECG Clue"], [20, 22, 30, 28]),
            new TableRow({
              children: [
                cell(para("RCA (proximal)", { bold: true, color: MID_BLUE, size: 20 }), { bg: LIGHT_BLUE }),
                cell(para("Inferior + posterior + RV", { size: 19 }), { bg: LIGHT_BLUE }),
                cell(para("Inferior MI ± RV infarction (most common)", { size: 19 }), { bg: LIGHT_BLUE }),
                cell(para("STE II > III or III > II; V1 STE = RV involvement", { size: 19, italic: true }), { bg: LIGHT_BLUE }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("RCA (posterior descending)", { bold: true, color: MID_BLUE, size: 20 }), { bg: WHITE }),
                cell(para("Inferior + posterior", { size: 19 }), { bg: WHITE }),
                cell(para("Inferior MI with posterior extension", { size: 19 }), { bg: WHITE }),
                cell(para("STE in II, III, aVF + STD in V1–V3", { size: 19, italic: true }), { bg: WHITE }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("LCx (nondominant)", { bold: true, color: ORANGE, size: 20 }), { bg: ORANGE_HL }),
                cell(para("Isolated posterior / lateral", { size: 19 }), { bg: ORANGE_HL }),
                cell(para("Isolated posterior MI (~5%); \"ECG silent\" on standard leads", { bold: true, size: 19 }), { bg: ORANGE_HL }),
                cell(para("STD V1–V3 only; posterior leads essential for diagnosis", { size: 19, italic: true }), { bg: ORANGE_HL }),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 4 — CLINICAL SCENARIOS
        // ══════════════════════════════════════════════════════════
        sectionHeading("4. When to Suspect Posterior MI — Clinical Triggers"),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            headerRow(["Clinical Scenario", "Action"], [50, 50]),
            new TableRow({
              children: [
                cell([
                  para("ST depression in V1–V3 with ischaemic symptoms", { bold: true, size: 20 }),
                  para("No other explanation (no RVH, no RBBB, no digoxin effect)", { size: 19, color: MED_GREY }),
                ], { bg: RED_HL }),
                cell([
                  para("Apply posterior leads V7–V9 immediately", { bold: true, color: RED, size: 20 }),
                  para("Consider STEMI equivalent if V7–V9 show ≥0.5 mm STE", { size: 19 }),
                ], { bg: RED_HL }),
              ],
            }),
            new TableRow({
              children: [
                cell([
                  para("Inferior STEMI (II, III, aVF elevation)", { bold: true, size: 20 }),
                  para("V1–V3 showing ST depression", { size: 19, color: MED_GREY }),
                ], { bg: LIGHT_GREY }),
                cell([
                  para("Posterior extension — larger infarct zone", { bold: true, color: DARK_RED, size: 20 }),
                  para("Also apply right-sided leads (V4R) to exclude RV infarction", { size: 19 }),
                ], { bg: LIGHT_GREY }),
              ],
            }),
            new TableRow({
              children: [
                cell([
                  para("Tall dominant R wave in V1 (new or unexplained)", { bold: true, size: 20 }),
                  para("With R ≥ S in V1, positive T; no RVH, no WPW, no RBBB", { size: 19, color: MED_GREY }),
                ], { bg: ORANGE_HL }),
                cell([
                  para("Suggests prior (old) posterior MI", { bold: true, color: ORANGE, size: 20 }),
                  para("Correlate with history, biomarkers, echo", { size: 19 }),
                ], { bg: ORANGE_HL }),
              ],
            }),
            new TableRow({
              children: [
                cell([
                  para("LCx territory ischaemia suspected", { bold: true, size: 20 }),
                  para("Standard 12-lead may be normal or minimally abnormal", { size: 19, color: MED_GREY }),
                ], { bg: LIGHT_BLUE }),
                cell([
                  para("LCx is 'ECG silent' — posterior leads are essential", { bold: true, color: MID_BLUE, size: 20 }),
                  para("V7–V9 STE will unmask circumflex occlusion", { size: 19 }),
                ], { bg: LIGHT_BLUE }),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 5 — MANAGEMENT PEARLS
        // ══════════════════════════════════════════════════════════
        sectionHeading("5. Management Pearls"),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            headerRow(["Clinical Point", "Detail"]),
            new TableRow({
              children: [
                cell(para("Reperfusion strategy", { bold: true, size: 20 }), { bg: RED_HL, width: 35 }),
                cell(para("Posterior MI = STEMI equivalent. Primary PCI is preferred. Do NOT delay based on 'only ST depression' on standard leads.", { size: 19 }), { bg: RED_HL, width: 65 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("Fibrinolytics & ST depression", { bold: true, size: 20 }), { bg: LIGHT_GREY, width: 35 }),
                cell(para("Fibrinolytics are normally CONTRAINDICATED for ST-segment depression — EXCEPT when posterior MI is suspected. This is a critical exception.", { bold: false, color: DARK_GREY, size: 19 }), { bg: LIGHT_GREY, width: 65 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("Nitrates — caution!", { bold: true, color: RED, size: 20 }), { bg: RED_HL, width: 35 }),
                cell(para("If RV infarction coexists (inferior + posterior + RV): AVOID nitrates and diuretics. Patient is preload-dependent. Volume loading is the treatment.", { size: 19 }), { bg: RED_HL, width: 65 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("Infarct size & prognosis", { bold: true, size: 20 }), { bg: ORANGE_HL, width: 35 }),
                cell(para("Inferior MI + posterior extension = larger infarct zone, lower EF, higher cardiovascular morbidity and mortality vs isolated inferior MI.", { size: 19 }), { bg: ORANGE_HL, width: 65 }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("RV infarction screening", { bold: true, size: 20 }), { bg: LIGHT_GREY, width: 35 }),
                cell(para("Apply right-sided leads (V4R) for ALL inferior STEMIs. ST elevation ≥1 mm in V4R is >90% sensitive and specific for RV injury.", { size: 19 }), { bg: LIGHT_GREY, width: 65 }),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 6 — DIFFERENTIAL DIAGNOSIS
        // ══════════════════════════════════════════════════════════
        sectionHeading("6. Differential Diagnosis — Tall R Wave in V1"),

        para("Before diagnosing posterior MI based on tall R wave in V1, exclude:", { size: 20, color: MED_GREY, spacing: { before: 60, after: 80 } }),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            headerRow(["Condition", "Distinguishing Feature"]),
            new TableRow({ children: [cell(para("Right Ventricular Hypertrophy (RVH)", { size: 20 }), { bg: LIGHT_GREY }), cell(para("Right axis deviation, P pulmonale, clinical context (COPD, pulmonary HTN)", { size: 19 }), { bg: LIGHT_GREY })] }),
            new TableRow({ children: [cell(para("Right Bundle Branch Block (RBBB)", { size: 20 }), { bg: WHITE }), cell(para("Wide QRS (≥0.12 sec), rSR' in V1, wide S waves in I and V6", { size: 19 }), { bg: WHITE })] }),
            new TableRow({ children: [cell(para("WPW Syndrome (Type A)", { size: 20 }), { bg: LIGHT_GREY }), cell(para("Short PR interval, delta wave, slurred QRS onset", { size: 19 }), { bg: LIGHT_GREY })] }),
            new TableRow({ children: [cell(para("Hypertrophic Cardiomyopathy", { size: 20 }), { bg: WHITE }), cell(para("Septal hypertrophy on echo, voltage criteria for LVH, clinical features", { size: 19 }), { bg: WHITE })] }),
            new TableRow({ children: [cell(para("Normal early R wave progression", { size: 20 }), { bg: LIGHT_GREY }), cell(para("No ischaemic symptoms, no ST changes, stable over time", { size: 19 }), { bg: LIGHT_GREY })] }),
            new TableRow({ children: [cell(para("Duchenne muscular dystrophy", { size: 20 }), { bg: WHITE }), cell(para("Clinical context, CK elevation, skeletal muscle involvement", { size: 19 }), { bg: WHITE })] }),
          ],
        }),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 7 — QUICK MEMORY AID
        // ══════════════════════════════════════════════════════════
        sectionHeading("7. Quick Memory Aid — The Posterior MI Triad in V1–V3"),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            new TableRow({
              children: [
                cell(
                  [
                    new Paragraph({
                      alignment: AlignmentType.CENTER,
                      spacing: { before: 120, after: 40 },
                      children: [new TextRun({ text: "↓ ST", bold: true, color: RED, size: 52, font: "Calibri" })],
                    }),
                    para("Horizontal ST depression", { align: AlignmentType.CENTER, bold: true, color: RED, size: 20 }),
                    para("in V1–V3", { align: AlignmentType.CENTER, color: MED_GREY, size: 18, spacing: { before: 0, after: 120 } }),
                  ],
                  { bg: RED_HL, borders: { top: solidBorder(RED, 12), bottom: solidBorder(RED, 12), left: solidBorder(RED, 12), right: solidBorder(RED, 12) } }
                ),
                cell(
                  [
                    new Paragraph({
                      alignment: AlignmentType.CENTER,
                      spacing: { before: 120, after: 40 },
                      children: [new TextRun({ text: "↑ T", bold: true, color: ORANGE, size: 52, font: "Calibri" })],
                    }),
                    para("Tall upright T wave", { align: AlignmentType.CENTER, bold: true, color: ORANGE, size: 20 }),
                    para("in V1–V3", { align: AlignmentType.CENTER, color: MED_GREY, size: 18, spacing: { before: 0, after: 120 } }),
                  ],
                  { bg: ORANGE_HL, borders: { top: solidBorder(ORANGE, 12), bottom: solidBorder(ORANGE, 12), left: solidBorder(ORANGE, 12), right: solidBorder(ORANGE, 12) } }
                ),
                cell(
                  [
                    new Paragraph({
                      alignment: AlignmentType.CENTER,
                      spacing: { before: 120, after: 40 },
                      children: [new TextRun({ text: "↑ R", bold: true, color: MID_BLUE, size: 52, font: "Calibri" })],
                    }),
                    para("Tall broad R wave", { align: AlignmentType.CENTER, bold: true, color: MID_BLUE, size: 20 }),
                    para("(≥ 0.04 sec) in V1–V2", { align: AlignmentType.CENTER, color: MED_GREY, size: 18, spacing: { before: 0, after: 120 } }),
                  ],
                  { bg: LIGHT_BLUE, borders: { top: solidBorder(MID_BLUE, 12), bottom: solidBorder(MID_BLUE, 12), left: solidBorder(MID_BLUE, 12), right: solidBorder(MID_BLUE, 12) } }
                ),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 80, after: 0 }, children: [] }),

        alertBox(
          "Remember:",
          "These are RECIPROCAL (mirror-image) changes. The posterior wall is infarcting but standard leads show the opposite — flip the ECG mentally. Apply V7–V9 to see the true ST elevation directly.",
          LIGHT_BLUE,
          MID_BLUE
        ),

        new Paragraph({ spacing: { before: 180, after: 0 }, children: [] }),

        // ══════════════════════════════════════════════════════════
        // SECTION 8 — STEP-BY-STEP DIAGNOSTIC ALGORITHM
        // ══════════════════════════════════════════════════════════
        sectionHeading("8. Step-by-Step Diagnostic Approach"),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            new TableRow({
              children: [
                cell(
                  para("STEP 1", { bold: true, color: WHITE, size: 22, align: AlignmentType.CENTER }),
                  { bg: BLUE, width: 12 }
                ),
                cell(
                  [
                    para("Obtain standard 12-lead ECG", { bold: true, size: 20 }),
                    para("Look for: ST depression in V1–V3, tall R in V1, upright T in V1–V3, concurrent inferior ST elevation", { size: 19, color: MED_GREY }),
                  ],
                  { bg: LIGHT_GREY, width: 88 }
                ),
              ],
            }),
            new TableRow({
              children: [
                cell(para("STEP 2", { bold: true, color: WHITE, size: 22, align: AlignmentType.CENTER }), { bg: MID_BLUE }),
                cell([
                  para("Apply posterior leads V7, V8, V9", { bold: true, size: 20 }),
                  para("Place at same horizontal level as V6 on the left posterior chest wall", { size: 19, color: MED_GREY }),
                ], { bg: WHITE }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("STEP 3", { bold: true, color: WHITE, size: 22, align: AlignmentType.CENTER }), { bg: BLUE }),
                cell([
                  para("Apply right-sided leads V3R–V6R (especially V4R)", { bold: true, size: 20 }),
                  para("Exclude / confirm concurrent RV infarction — critical for management", { size: 19, color: MED_GREY }),
                ], { bg: LIGHT_GREY }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("STEP 4", { bold: true, color: WHITE, size: 22, align: AlignmentType.CENTER }), { bg: RED }),
                cell([
                  para("ST elevation ≥ 0.5 mm in V7–V9 = STEMI equivalent", { bold: true, color: RED, size: 20 }),
                  para("Activate cath lab. Primary PCI preferred. If no PCI available, fibrinolytics are indicated (exception to ST-depression rule).", { size: 19 }),
                ], { bg: RED_HL }),
              ],
            }),
            new TableRow({
              children: [
                cell(para("STEP 5", { bold: true, color: WHITE, size: 22, align: AlignmentType.CENTER }), { bg: MID_BLUE }),
                cell([
                  para("If RV infarction confirmed (V4R STE ≥ 1 mm)", { bold: true, size: 20 }),
                  para("Avoid nitrates and diuretics. Give IV fluids. Maintain preload. Avoid vasodilators.", { size: 19, color: MED_GREY }),
                ], { bg: WHITE }),
              ],
            }),
          ],
        }),

        new Paragraph({ spacing: { before: 100, after: 0 }, children: [] }),

      ],
    },
  ],
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync("/home/daytona/workspace/posterior-mi-guide/Posterior_MI_ECG_Quick_Reference.docx", buffer);
  console.log("Document created successfully.");
}).catch(err => {
  console.error("Error:", err);
  process.exit(1);
});

Running Command

cd /home/daytona/workspace/posterior-mi-guide && node create_guide.js

Running Command

python /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/workspace/posterior-mi-guide/Posterior_MI_ECG_Quick_Reference.docx

Running Command

python3 -c " import zipfile, os path = '/home/daytona/workspace/posterior-mi-guide/Posterior_MI_ECG_Quick_Reference.docx' print('File size:', os.path.getsize(path), 'bytes') with zipfile.ZipFile(path, 'r') as z: print('Files in docx:') for name in z.namelist(): print(' ', name) "

The file is valid - it's a proper ZIP with all expected DOCX components. The document is ready.

Your Word document is ready for download:

Posterior MI ECG Quick Reference

Word Document · DOCX

What's inside the guide (8 sections):

12-Lead ECG Findings - Color-coded table of all 4 reciprocal changes in V1-V3 (horizontal STD, tall R, upright T, R/S ratio ≥1) with mechanisms
Posterior Leads V7-V9 - Placement guide and the ≥0.5 mm ST elevation threshold
Culprit Vessel Patterns - RCA proximal vs RCA PDA vs nondominant LCx with ECG clues for each
Clinical Triggers - 4 scenarios when to suspect posterior MI (including the "ECG silent" LCx)
Management Pearls - Reperfusion strategy, fibrinolytic exception, nitrate caution in RV infarction
Differential Diagnosis - 6 conditions that mimic tall R in V1
Quick Memory Aid - Large visual 3-box triad: ↓ ST / ↑ T / ↑ R
Step-by-Step Diagnostic Algorithm - 5 color-coded steps from 12-lead to cath lab activation

This is a shared conversation. Sign in to Orris to start your own chat.