ECG Blog #479 — Technical Misadventures to Know!

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INTRO: I have added this Tab on Technical "Misadventures" — to the Menu at the top of every page in this ECG Blog:

— Where to find this LINK in the Top Menu! —

All-too-often lead reversals, unsuspected artifact, and other "technical misadventures" go unrecognized — with resultant erroneous diagnostic and therapeutic implications. 

• In the hope of facilitating recognition of these cases — I am developing an ongoing listing on this page with LINKS to examples that I’ve published in this ECG Blog, as well as in Dr. Smith’s ECG Blog where I frequently write commentaries.

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Sample CASE #1:

• What type of "technical misadventure" is present in Figure-1?

Figure-1: How would you interpret this ECG?

QUESTIONS:

• What is the "culprit artery" in Figure-1?
•      — What kind of "lead reversal" ? 

This case is from ECG Blog #375. Click this link for full discussion!

• HINT: This is not a high-lateral infarction ...

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Sample CASE #2:

• What type of "technical misadventure" is present in Figure-2?

Figure-2: How would you interpret this ECG?

QUESTIONS:

• Did you recognize the MI in Figure-2?
•      — What kind of "lead reversal" ? 

This case is from ECG Blog #175. Click this link for full discussion!

• HINT: There was no infarction — and no lead reversal ...

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Suggestion:

My favorite on-line “Quick GO-TO” reference for the most common types of lead misplacement comes from LITFL ( = Life-In-The-Fast-Lane). I have used the superb web page they post in their web site on this subject for years. It’s EASY to find — Simply put in, “LITFL Lead Reversal” in the Search bar — and the link comes up instantly. 

• This LITFL web page describes the 7 most common lead reversals. There are other possibilities (ie, in which there may be misplacement of multiple leads) — but these are less common and more difficult to predict.
• When I suspect a type of lead reversal that I am less familiar with — I simply review those 7 most common types of lead reversal on the LITFL page — and see if any of the ECG examples they provide seems to apply. 
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• PEARL: — I’ve summarized in Figure-3 those tips that have helped me most over the years to rapidly recognize tracings in which lead reversal is likely.

Figure-3: Tips for recognizing lead reversal (See text).

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ECG Media PEARL #72 (5:45 minutes Audio) — Reviews how to suspect Limb Lead Reversal (especially LA-RA lead reversal).

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EXAMPLES of Lead Reversal on Dr. Smith's Blog:

Technical errors featuring a variety of lead reversal placements remain a surprisingly common “mishap” of everyday practice. As a result — I'll continue to periodically publish clinical examples of lead misplacement. For review — GO TO:

• The June 4, 2018 post (LA-LL reversal).
• The July 29, 2018 post (LA-RA reversal).
• The November 4, 2018 post (Leads V1,V2 misplacement).
• The February 11, 2020 post (LA-RA reversal).
• The March 18, 2020 post (LA-RA reversal).
• The July 28, 2020 post (RA-LL reversal).
• The August 28, 2020 post (LA-LL reversal).
• The November 19, 2020 post (LA-LL reversal).
• The November 27, 2021 post (LA-RA reversal).
• The April 17, 2022 post (Leads V1,V2 misplacement).
• The May 5, 2022 post (LA-RA reversal).
• The May 24, 2022 post (LA-LL reversal).
• The May 26, 2022 post (LA-LL reversal).
• The August 17, 2022 post (LA-RA reversal).
• The November 8, 2022 post (Leads V1,V2 + Pulse-Tap Artifact).
• The December 18, 2022 post (Leads V1,V2).
• The May 13, 2023 post (LA-RA reversal).
• The May 30, 2023 post (LA-RA reversal). 
• The January 6, 2024 post (RA-LL reversal).
• The June 25, 2024 post (LA-LL reversal; V1,V2 misplacement).
• The October 12, 2024 post (BNicholson- flat lead II = RA-RL reversal).
• The April 16, 2025 post (RA-RL reversal- flat lead II ).

Lead Reversals on My ECG Blog:

• ECG Blog #264 — Review of Limb Lead Reversals (ie, LA-RA lead reversal in a patient with an acute MI). Please also see the 7/29/2024 ADDENDUM to this post for another LA-RA reversal — V1,V2 misplacement — and an almost flat line in lead II).
• ECG Blog #330 — LA-RA reversal.
• ECG Blog #375 — LA-LL lead reversal.
• ECG Blog #396 — Flat line in lead I. 
• ECG Blog #462 — Leads are "off" (bizarre frontal plane axis).
• ECG Blog #463 — LA-RA reversal.

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Links to Examples of ARTIFACT:

More technical "misadventures" are referenced here — some from Dr. Smith's ECG Blog — some from My ECG Blog — and some from other sources.

• The April 25, 2025 post — Hypothermia (Shiver artifact seen on repeat ECG — but not on the initial ECG).
• The February 2, 2025 post — Lead Overlap masks true voltage!
• The June 15, 2024 post — Deceptive telemetry artifact!
• The June 10, 2024 post — Bizarre = Artifact?
• The May 18, 2024 post — Filters; RA Artifact.
• The March 25, 2025 post — Artifact distorts limb lead complexes!
• The February 18, 2024 post — About Filters; PTA.
• The January 15, 2024 post — All about ARTIFACT!
• The September 15, 2023 post — for PTA (Pulse-Tap Artifact).
• The March 17, 2023 post — for PTA.
• The January 17, 2023 post — for PTA.
• The October 21, 2022 post — for "artifactual VT".
• The November 10, 2020 post — for PTA.
• The October 17, 2020 post — for a 70-year old woman with "Artifactual VT".
• The September 27, 2019 post — for the Rowlands & Moore article with the above-noted formulas for recognizing the “culprit” extremity.
• The September 22, 2019 post — intermittent ST-T wave artifact.
• The August 26, 2019 post — baseline artifact.
• The January 30, 2018 post — for PTA. 
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• Brief review by Tom Bouthillet on some common causes of artifact.
• Additional review of ECG artifacts by Pérez-Riera et al (Ann Noninvasic Electrocardiol 23:e12494, 2018)
• VT Artifact — by Knight et al: NEJM 341:1270-1274, 1999.
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• ECG Blog #148 — Artifact simulating VFib.
• ECG Blog #132 — More VT-VFib artifact.
• ECG Blog #139 — Artifact simulating AFlutter.
• ECG Blog #44 — Parkinsonian Tremor vs AFlutter. 
• ECG Blog #255 — Left Leg artifact. 
• ECG Blog #201 — Should the cath lab be activated? 
• ECG Blog #432 — Not PMVT — but ARTIFACT!
• ECG Blog #478 — Artifact simulates Torsades ...