The 5 underrecognized ECG patterns of ACS

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LMCA occlusion: High incidence of cardiogenic shock, need immediate PCI +/- CABG, not tPA.

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LAD-D1 occlusion pattern:
1. High lateral STEMI (South Africa flag sign).
2. Highly predictive (89% PPV) of anterior wall MI.

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High Lateral STEMI (South Africa Flag Sign)

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Posterior wall MI: True STEMI, can be easily missed if isolated (ECG #3). May get leads V7,8,9 for confirmation. Inferior wall STEMI also noted in ECG #1 and #2.

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Wellens' syndrome: Subacute critical occlusion of proximal LAD or mid-LAD. Avoid excercise stress test.

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De Winter's T: Anterior STEMI equivalent due to acute proximal LAD occlusion.

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References:
http://rebelem.com/five-ecg-patterns-you-must-know/
http://lifeinthefastlane.com/
http://www.slideshare.net/MohamedHamoda/stemi-equivalents

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