Vascular Territory Prediction Model
Select EKG changes and echo wall abnormalities. The calculator estimates the most likely vascular territory and culprit artery, and suggests echo views to verify.
EKG findings
Check what you see (use ST elevation for territory; posterior uses STD V1–V3 or STE V7–V9).
Echo wall‑motion findings
Regional hypokinesis/akinesis by wall.
Context
Calculator updates on click. Reset clears all inputs.
Logic (transparent mapping)
Territory likelihood
Top territory reflects combined EKG and echo signals. Posterior includes inferolateral wall in modern nomenclature.
Likely culprit artery
Top line auto‑highlights. Dominance and wrap‑around variants can shift probability.
Why this result?
EKG → Coronary Artery → Echo Wall-Motion Segments
| EKG leads | Coronary Artery | Territory | TTE Wall Motion |
|---|---|---|---|
| V1–V2 (septal) | LAD (septal perforators; proximal LAD if large) | Anteroseptal | PSAX (pap level) for septum, A4C for septal wall, A3C for anteroseptal, APLAX for basal anteroseptal |
| V3–V4 (anterior) | LAD | Anterior/apex | A2C for anterior/apex, PSAX for anterior, A3C for anterior/apex |
| I, aVL (high lateral) | LCx (OM) or LAD (diagonal) | High lateral | PSAX for lateral wall, A3C for anterolateral, A4C for lateral mid/apex |
| V5–V6 (lateral) | LCx (OM) > LAD (diagonal) | Lateral | A4C for lateral wall/apex, PSAX for basal/mid lateral |
| II, III, aVF (inferior) | RCA (dominant) > LCx (if left dominant) | Inferior | A2C for inferior/apex, PSAX for basal/mid inferior |
| “Posterior” (ST↓ V1–V3; tall R V1–V2; STE V7–V9) | RCA (dominant) or LCx | Posterior/inferolateral | PSAX for posterior, A3C for inferolateral |
| V1–V4 with right-sided V4R STE | Proximal RCA | RV infarct (± inferior LV) | A4C/RV-focused views; TAPSE/TDI impaired |
How to use this clinically
- Anterior/LAD: STE/Qs in V2–V4 → look for anterior/anteroseptal/apical hypokinesis
- Septal/LAD: changes in V1–V2 → assess septal wall in PSAX/A4C
- Lateral (LCx/Diagonal): I, aVL, V5–V6 → inspect lateral wall/apical lateral in A4C/PSAX
- Inferior (RCA>LCx): II, III, aVF → check inferior/apical inferior in A2C/PSAX; often reciprocal ST depression in I/aVL
- Posterior: ST depression V1–V3 or STE V7–V9 → evaluate posterior/inferolateral in PSAX/A3C
- RV infarct: Inferior STEMI + V4R STE → look for RV free-wall hypokinesis, low TAPSE
Echo view → wall cheat-sheet
| Echo view | Walls/segments primarily seen | Typical culprit when abnormal |
|---|---|---|
| A4C | Septal and lateral walls; apex | LAD (septal/anterior), LCx/Diagonal (lateral) |
| A2C | Inferior and anterior walls; apex | RCA/LCx (inferior), LAD (anterior) |
| A3C (Apical long-axis) | Anteroseptal and inferolateral walls; apex | LAD (anteroseptal), LCx/RCA (inferolateral) |
| PLAX | Basal/mid anteroseptal and inferolateral/posterior slices | LAD (anteroseptal), LCx/RCA (posterolateral) |
| PSAX (pap level) | Full circumferential slice of LV | LAD (anterior/septal), LCx/RCA (inferolateral/inferior) |
Reciprocal patterns
| STE territory | Common reciprocal ST depression |
|---|---|
| Anterior | Inferior leads |
| Lateral | Inferior leads |
| Inferior | High lateral leads (I, aVL) |
| Posterior | Anterior leads (appears as ST depression V1–V3) |
Pearls & pitfall
- Coronary dominance matters: LCx can cause inferior changes in left-dominant systems
- Wrap-around LAD can mimic inferior/apical changes
- Multivessel/LM disease may cause diffuse depression with aVR elevation; echo shows global hypokinesis
- Posterior MI: Often missed unless V7–V9 placed; echo shows inferolateral/posterior wall abnormalities
- RV infarct: Check RV size/function, TAPSE/TDI S’, and IVC; preload sensitive
- New LBBB or paced rhythm: Use Sgarbossa criteria; echo can still show regional dysfunction
- Chronic infarct: Wall thinning, bright echogenicity, dyskinesis or aneurysm formation; Q waves match territory