lead misplacement

V1-2 too high

PMID 28213958:

1435 ECGs randomly selected
- Biphasic P waves in V2 in only 10.5%
- Inverted P waves in V2 in only 4.8%
- Usually caused by:
  - left atrial abnormalities,
  - septal MI,
  - V1-V2 placed too high on the precordium

As the leads are moved higher, V1-V2 demonstrate…

False incomplete RBBB type pattern
- Often with an Rsr’ pattern as opposed to typical (I)RBBB patterns that have rsR’
- (typically have a larger second upward deflection, consider lead misplacement when the first upward deflection is higher than the second)
ST elevation
septal Q waves
TWI in V1-V2 (usually not out to V3)
- Normal in V1, but not usually normal in V2
Inverted P waves
- Normal in V1, but not usually normal in V2

References

MacAlpin RN. Significance of a negative sinus P wave in lead V2 of the clinical electrocardiogram. Ann Noninvasive Electrocardiol. 2017 Sep;22(5):e12432. Epub 2017 Feb 18. PMID: 28213958

Walsh B. Misplacing V1 and V2 can have clinical consequences. Am J Emerg Med. 2018 May;36(5):865-870. Epub 2018 Feb 8. PMID: 29472037

Abobaker A, Rana RM. V1 and V2 pericordial leads misplacement and its negative impact on ECG interpretation and clinical care. Ann Noninvasive Electrocardiol. 2021 Jul;26(4):e12844. Epub 2021 Apr 4. PMID: 33817908