Myocardial Infarction with Paradoxical ST-segment Elevation Migration: A Case Study

Myocardial Infarction with Paradoxical ST-segment Elevation Migration: A Case Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Myocardial Infarction with Paradoxical ST-segment Elevation Migration: A Case Study Yu-An Chen, Cheng-Chieh Huang, Tsung-Han Lee, Yan-Ren Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7778513/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Dec, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted 12 You are reading this latest preprint version Abstract We present the case of a 47-year-old man with chest pain whose electrocardiogram (ECG) revealed ST-segment elevation in different territories within one hour . The cardiac catheterization findings were consistent with the second ECG. The migration of ST-segment elevation may be due to various reasons, including aortic dissection, coronary vasospasm, thrombus migration, and pericarditis. However, in our case, limb lead reversal was the suspected cause of migration of ST-segment elevation. The accurate identification of ST-segment elevation is important to the cardiologist in order to determine the culprit vessel. Moreover, early reperfusion of the coronary artery is associated with better prognosis. ST-segment migration limbs reversal wandering ST-segment elevation Figures Figure 1 Figure 2 Figure 3 Introduction ST-elevation myocardial infarction (STEMI) is a life-threatening condition, with the electrocardiogram (ECG) being an essential tool for its prompt diagnosis. Besides, identifying the culprit vessel on the ECG is critical for guiding reperfusion therapy. However, ST-segment elevation migration may occur in certain cases, which can be attributed to several factors, including lead misplacement, coronary vasospasm, thrombus migration, aortic dissection, or even acute pericarditis. Although prevention of such errors is important, recognizing them when they occur is also essential. Case report A 47-year-old man presented with acute-onset diaphoresis, chest pain and numbness in his left arm. At the initial hospital, he had stable vital signs and was fully alert. The first ECG revealed an ST-segment elevation over leads I and aVL, and ST depression over leads II, III and aVF (Fig. 1 ). Laboratory investigations revealed non-specific findings. Owing to the suspicion of STEMI, he was transferred to our hospital for further coronary angiography. Repeated ECG showed Q waves with ST-segment elevation over leads II, III and aVF with ST depression in leads I, aVL, and V2–5, which were suspected reciprocal changes (Fig. 2 ). Right-sided ECG demonstrated ST-segment elevation over V5–6 (Fig. 3 ). As a result, dual antiplatelet (aspirin plus ticagrelor) therapy with heparin was administered. An emergent percutaneous coronary intervention (PCI) revealed two-vessel coronary artery disease with the culprit lesion located at the right coronary artery. After 3 days of treatment in the cardiac care unit, he was transferred to the general ward and discharged uneventfully. Discussion Twelve-lead ECG is the primary diagnostic tool for STEMI; therefore, its improper acquisition can result in misinterpretation and potentially lead to unnecessary and costly evaluations [ 1 ]. Additionally, early identification of the culprit vessel prior to reperfusion therapy may shorten the procedure time and improve outcomes [ 2 ]. The ECG is frequently performed as follow-up test in some conditions, including inter-hospital transference, vital sign changes, or symptom deterioration. The migration or different degrees of ST-segment elevation are sometimes noted. This migration might be caused by several etiologies, including lead misplacement [ 3 , 4 ], coronary vasospasm [ 5 ], thrombus migration, aortic dissection [ 6 ], and even acute pericarditis [ 7 ]. In our case, the apparent ST-segment elevation migration was attributed to lead reversal, as confirmed by the PCI report. ST depression in lead III with a negative P wave was found in the first ECG, but the second ECG showed ST-segment elevation in lead III with a positive P wave. According to the Einthoven triangle, lead III is the voltage difference between the LL (Left Leg) and LA (Left Arm) electrodes. Therefore, when LA and LL lead misplacement is present, the wave form in lead III becomes inverted. Besides, leads I and II are the voltage differences between the LA and RA (Right Arm) electrodes and between the LL and RA electrodes, respectively. In LA/LL lead reversal, we noted the switch place of leads I and II, which may come from the opposite lead electricity direction from the reversal. The waveform of aVL and aVF changes with each other in the same way. The reported prevalence of lead misplacement from all ECGs was 0.4%–4% [ 1 ]. Lead reversal commonly occurs in the right and left arms, accounting for 20% of all lead reversals; contrarily, LA/LL lead reversal was the least common [ 1 , 8 ]. One study showed 90% sensitivity for detecting LA/LL lead reversal, if the P amplitude is higher in lead I than in lead II and a terminal positive P wave is seen in lead III [ 9 ]. This mistake is harder to recognize in the absence of a previous comparative ECG or in the presence of artifacts, non-sinus or paced rhythms, and additional lead reversals [ 1 ]. Generally, an incorrect peripheral electrode cable connection without neutral electrode involvement can be recognized by unusual P-QRS patterns, such as negative P-QRS in lead I or II, positive P-QRS in lead aVR, P–QRS axis changes, or abnormal precordial R-wave progression. For precordial leads, reversal can be detected by careful inspection of the precordial transition [ 8 ]. Aside from the ST-segment elevation migration, limb lead misplacement can cause either a pseudo-infarct pattern or a disappearance of both inferior and lateral infarcts, which may lead to unnecessary cardiac evaluation. The frequency of lead misplacement increases in acute medical care setting as well [ 10 ]. Thus, as a preventive measure, we recommend labeling of each electrode in a familiar language. Besides, performing serial ECGs can also assist in identifying potential lead misplacements. In conclusion, accidental ECG electrode misplacement can result in misdiagnosis, inappropriate treatment decisions, and potentially adverse impacts on patient prognosis. Apart from ensuring clinicians are familiar with the unusual P–QRS patterns, using clear familiar-language labeling on each electrode—combined with serial ECG reviews, particularly during inter-hospital transfers or clinical deterioration—plays an important role in the timely recognition of lead misplacement. Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Institutional Review Board of Changhua Christian Hospital at 250812. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee. Written informed consent was obtained from the participant. Consent for publication Written, informed consent was obtained from the patient. Availability of data and materials Not applicable. Competing interests The authors declare no competing interests. Funding Not applicable. Authors' contributions YAC: Collection of data and case details, drafting the article and final approval of the version to be published. CCH, THL, YRL: Conception of the work, critical revision and final approval of the version to be published. Acknowledgements Not applicable. References Velagapudi P, Turagam MK, Ritter S, Dohrmann ML. Left arm/left leg lead reversals at the cable junction box: A cause for an epidemic of errors. J Electrocardiol 2017 Jan-Feb;50(1):111–4. 10.1016/j.jelectrocard.2016.06.011 Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour.Lancet. 1996;348(9030):771–5. 10.1016/S0140-6736(96)02514-7 Akel R, Saeed M, Ware DL, Chamoun AJ, Birnbaum Y. Unusual evolution of ST elevation acute myocardial infarction. Ann Noninvasive Electrocardiol. 2004;9(4):410–4. 10.1111/j.1542-474X.2004.94572.x . Kidambi BR, Veeraraghavan S, Vijay S. Wandering ST-segment in acute coronary syndrome (the Einthoven’s twist). Cureus. 2023;15(12):e50089. 10.7759/cureus.50089 . Mirza I, Orr W, Porto I. A case of multivessel coronary artery spasm resulting in wandering ST segment elevation. Int J Cardiol. 2006;109(1):121–4. 10.1016/j.ijcard.2005.03.066 . Inoue T, Fukumoto Y, Mohri M, et al. Wandering ST-segment elevation. Circulation. 2003;108(14):e102–3. 10.1161/01.CIR.0000091886.24045.84 . Xiao Y, Zhou R. Migrating localized ST-segment elevation with ongoing chest pain. JAMA Intern Med. 2023;183(9):1005–6. 10.1001/jamainternmed.2023.1723 . Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection during electrocardiographic recording. Europace. 2007;9(11):1081–90. 10.1093/europace/eum198 . Abdollah H, Milliken JA. Recognition of electrocardiographic left arm/left leg lead reversal. Am J Cardiol. 1997;80(9):1247–9. 10.1016/s0002-9149(97)00656-5 . Rudiger A, Hellermann JP, Mukherjee R, Follath F, Turina J. Electrocardiographic artifacts due to electrode misplacement and their frequency in different clinical settings. Am J Emerg Med. 2007;25(2):174–8. 10.1016/j.ajem.2006.06.018 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Dec, 2025 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 14 Nov, 2025 Reviews received at journal 13 Nov, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviews received at journal 12 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers invited by journal 14 Oct, 2025 Editor assigned by journal 13 Oct, 2025 Submission checks completed at journal 13 Oct, 2025 First submitted to journal 04 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7778513","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":534950164,"identity":"94a2c968-0fae-4c06-9875-c95e7b6bed42","order_by":0,"name":"Yu-An Chen","email":"","orcid":"","institution":"Changhua Christian Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu-An","middleName":"","lastName":"Chen","suffix":""},{"id":534950166,"identity":"abcef303-88f4-47c2-bd90-bada5cdee428","order_by":1,"name":"Cheng-Chieh Huang","email":"","orcid":"","institution":"Changhua Christian 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07:50:21","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":34609,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7778513/v1/f50b44629ae5a1e3064f1a5b.html"},{"id":94638462,"identity":"3a2816b1-b349-4c2f-afa8-3c0bf8ad6686","added_by":"auto","created_at":"2025-10-29 07:29:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77257,"visible":true,"origin":"","legend":"\u003cp\u003eFirst electrocardiogram (ECG) revealing ST-segment elevation in leads I and aVL and ST depression in leads II, III, and aVF.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7778513/v1/51968dc6c976702c8fb9922e.png"},{"id":94638461,"identity":"63c20d05-7c86-4f83-b54a-40e824cefd2f","added_by":"auto","created_at":"2025-10-29 07:29:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":98547,"visible":true,"origin":"","legend":"\u003cp\u003eSecond electrocardiogram (ECG) performed approximately 30 minutes later revealed Q waves with ST-segment elevation in leads II, III, and aVF and ST depression in leads I, aVL, and V2–5.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7778513/v1/bac8100fc90d32bc8b153e1a.png"},{"id":94640747,"identity":"cc9a4ed2-758f-4c07-9b42-5f8353c320e1","added_by":"auto","created_at":"2025-10-29 07:50:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":119478,"visible":true,"origin":"","legend":"\u003cp\u003eRight-sided electrocardiogram (ECG) revealing ST-segment elevation over V5–6.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7778513/v1/66aa61512dd4bdc8e882b89f.png"},{"id":99172323,"identity":"7b32360b-2965-4506-a1f2-11f483eaaaef","added_by":"auto","created_at":"2025-12-29 16:07:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":512964,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7778513/v1/c7c000c8-10e1-449a-a3b2-076d808369e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Myocardial Infarction with Paradoxical ST-segment Elevation Migration: A Case Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eST-elevation myocardial infarction (STEMI) is a life-threatening condition, with the electrocardiogram (ECG) being an essential tool for its prompt diagnosis. Besides, identifying the culprit vessel on the ECG is critical for guiding reperfusion therapy. However, ST-segment elevation migration may occur in certain cases, which can be attributed to several factors, including lead misplacement, coronary vasospasm, thrombus migration, aortic dissection, or even acute pericarditis. Although prevention of such errors is important, recognizing them when they occur is also essential.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 47-year-old man presented with acute-onset diaphoresis, chest pain and numbness in his left arm. At the initial hospital, he had stable vital signs and was fully alert. The first ECG revealed an ST-segment elevation over leads I and aVL, and ST depression over leads II, III and aVF (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Laboratory investigations revealed non-specific findings. Owing to the suspicion of STEMI, he was transferred to our hospital for further coronary angiography. Repeated ECG showed Q waves with ST-segment elevation over leads II, III and aVF with ST depression in leads I, aVL, and V2\u0026ndash;5, which were suspected reciprocal changes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Right-sided ECG demonstrated ST-segment elevation over V5\u0026ndash;6 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). As a result, dual antiplatelet (aspirin plus ticagrelor) therapy with heparin was administered. An emergent percutaneous coronary intervention (PCI) revealed two-vessel coronary artery disease with the culprit lesion located at the right coronary artery. After 3 days of treatment in the cardiac care unit, he was transferred to the general ward and discharged uneventfully.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTwelve-lead ECG is the primary diagnostic tool for STEMI; therefore, its improper acquisition can result in misinterpretation and potentially lead to unnecessary and costly evaluations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, early identification of the culprit vessel prior to reperfusion therapy may shorten the procedure time and improve outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The ECG is frequently performed as follow-up test in some conditions, including inter-hospital transference, vital sign changes, or symptom deterioration. The migration or different degrees of ST-segment elevation are sometimes noted. This migration might be caused by several etiologies, including lead misplacement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], coronary vasospasm [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], thrombus migration, aortic dissection [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and even acute pericarditis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our case, the apparent ST-segment elevation migration was attributed to lead reversal, as confirmed by the PCI report. ST depression in lead III with a negative P wave was found in the first ECG, but the second ECG showed ST-segment elevation in lead III with a positive P wave. According to the Einthoven triangle, lead III is the voltage difference between the LL (Left Leg) and LA (Left Arm) electrodes. Therefore, when LA and LL lead misplacement is present, the wave form in lead III becomes inverted. Besides, leads I and II are the voltage differences between the LA and RA (Right Arm) electrodes and between the LL and RA electrodes, respectively. In LA/LL lead reversal, we noted the switch place of leads I and II, which may come from the opposite lead electricity direction from the reversal. The waveform of aVL and aVF changes with each other in the same way.\u003c/p\u003e\u003cp\u003eThe reported prevalence of lead misplacement from all ECGs was 0.4%\u0026ndash;4% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Lead reversal commonly occurs in the right and left arms, accounting for 20% of all lead reversals; contrarily, LA/LL lead reversal was the least common [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One study showed 90% sensitivity for detecting LA/LL lead reversal, if the P amplitude is higher in lead I than in lead II and a terminal positive P wave is seen in lead III [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This mistake is harder to recognize in the absence of a previous comparative ECG or in the presence of artifacts, non-sinus or paced rhythms, and additional lead reversals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGenerally, an incorrect peripheral electrode cable connection without neutral electrode involvement can be recognized by unusual P-QRS patterns, such as negative P-QRS in lead I or II, positive P-QRS in lead aVR, P\u0026ndash;QRS axis changes, or abnormal precordial R-wave progression. For precordial leads, reversal can be detected by careful inspection of the precordial transition [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Aside from the ST-segment elevation migration, limb lead misplacement can cause either a pseudo-infarct pattern or a disappearance of both inferior and lateral infarcts, which may lead to unnecessary cardiac evaluation. The frequency of lead misplacement increases in acute medical care setting as well [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Thus, as a preventive measure, we recommend labeling of each electrode in a familiar language. Besides, performing serial ECGs can also assist in identifying potential lead misplacements.\u003c/p\u003e\u003cp\u003eIn conclusion, accidental ECG electrode misplacement can result in misdiagnosis, inappropriate treatment decisions, and potentially adverse impacts on patient prognosis. Apart from ensuring clinicians are familiar with the unusual P\u0026ndash;QRS patterns, using clear familiar-language labeling on each electrode\u0026mdash;combined with serial ECG reviews, particularly during inter-hospital transfers or clinical deterioration\u0026mdash;plays an important role in the timely recognition of lead misplacement.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Institutional Review Board of Changhua Christian Hospital at 250812. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee. Written informed consent was obtained from the participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten, informed consent was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYAC: Collection of data and case details, drafting the article and final approval of the version to be published. CCH, THL, YRL: Conception of the work, critical revision and final approval of the version to be published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVelagapudi P, Turagam MK, Ritter S, Dohrmann ML. Left arm/left leg lead reversals at the cable junction box: A cause for an epidemic of errors. J Electrocardiol 2017 Jan-Feb;50(1):111\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jelectrocard.2016.06.011\u003c/span\u003e\u003cspan address=\"10.1016/j.jelectrocard.2016.06.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoersma E, Maas AC, Deckers JW, Simoons ML. 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Am J Emerg Med. 2007;25(2):174\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajem.2006.06.018\u003c/span\u003e\u003cspan address=\"10.1016/j.ajem.2006.06.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ST-segment migration, limbs reversal, wandering ST-segment elevation","lastPublishedDoi":"10.21203/rs.3.rs-7778513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7778513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe present the case of a 47-year-old man with chest pain whose electrocardiogram (ECG) revealed ST-segment elevation in different territories within one hour . The cardiac catheterization findings were consistent with the second ECG. The migration of ST-segment elevation may be due to various reasons, including aortic dissection, coronary vasospasm, thrombus migration, and pericarditis. However, in our case, limb lead reversal was the suspected cause of migration of ST-segment elevation. The accurate identification of ST-segment elevation is important to the cardiologist in order to determine the culprit vessel. Moreover, early reperfusion of the coronary artery is associated with better prognosis.\u003c/p\u003e","manuscriptTitle":"Myocardial Infarction with Paradoxical ST-segment Elevation Migration: A Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 07:29:40","doi":"10.21203/rs.3.rs-7778513/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-14T19:25:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T21:40:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330513894927752715581794014830104864200","date":"2025-11-12T20:25:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T05:38:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211461760991663906645316185499454189801","date":"2025-11-12T03:37:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287936599568040438227318284903273113562","date":"2025-11-11T14:24:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173963892366236598906496941944123134857","date":"2025-11-10T17:41:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194399051216274922879442910682090553578","date":"2025-11-10T15:44:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T19:28:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-13T08:24:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-13T08:22:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2025-10-04T08:36:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f69de2a-11a7-45c4-9fdd-be58f4792aa8","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:01:12+00:00","versionOfRecord":{"articleIdentity":"rs-7778513","link":"https://doi.org/10.1186/s12245-025-01090-0","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2025-12-22 15:57:45","publishedOnDateReadable":"December 22nd, 2025"},"versionCreatedAt":"2025-10-29 07:29:40","video":"","vorDoi":"10.1186/s12245-025-01090-0","vorDoiUrl":"https://doi.org/10.1186/s12245-025-01090-0","workflowStages":[]},"version":"v1","identity":"rs-7778513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7778513","identity":"rs-7778513","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}