Most dangerous ECGs don’t always have the biggest ST elevation.

The most dangerous ECGs don’t always have the biggest ST elevation.

If you’re staring at V2–V3 trying to decide between Early Repolarization and a subtle LAD occlusion, stop looking at the ST segment and look at the Terminal QRS.

What is Terminal QRS Distortion? It’s a binary finding. In V2 or V3, ask yourself:

Is the S-wave gone?

Is the J-wave gone?

If the answer to both is YES, you are looking at Grade III ischemia.

The Stats:

Specificity: ~100% vs. Early Repolarization. BER simply doesn’t do this.

Sensitivity: ~20–35%. It won’t catch every STEMI, but when it’s there, it’s a “rule-in” sign.

Risk: Associated with larger infarct size (CMR-proven) and higher rates of heart failure.

The Logic: This is depolarization failing in real-time. Severe ischemia slows conduction so much that the end of the QRS gets “swallowed” by the repolarization phase.

Takeaway: Millimeters can lie. Morphology rarely does. If the S-wave is missing in the anterior leads, call the lab.

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