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It’s apparently due to constant negative current pushing down the rest of ECG segments. One popular theory says that the current of injury as we see as ST segment elevation in surface ECG is actually an illusion. Is reciprocal ST segment changes occur only in STEMI ? Can it occur in UA/NSTEMI ? Even after 100 years of electro cardiology the electrophysiological mechanism of ST elevation in STEMI and ST depression in Unstable angina is still in the hypothetical stages. Still, it may require a FFR to confirm ischemia in the contra lateral artery. Coronary angiogram would provide definite answer to the speculations in most.One can detect ischemic the wall motion defect in the segment in dispute. (Also read – A related article dual acute coronary syndrome in this site ) Worsening with thrombolysis would suggest ST depression in V1V2 and v3 is indeed an episode of true NSTEMI of LAD, where thrombolysis is contraindicated.Persistence of ST depression even after thrombolysis or PCI to IRA.Disproportionate ST segment depression (ST elevation in inferior lead is 2 mm while ST depression in v1,v2, v3 is > 3 mm ).If its a pure electrical phenomenon they should be linked in time. In true ischemia, both patterns are not temporally related in time.Patients with pure electrical reciprocal changes are relatively quiet and severe distress is uncommon. Most of these patients will present in a scenario of post infarct persistent angina. Logically true ischemia patients should suffer from double dose of angina (Infarct pain plus ischemic).How to differentiate reciprocal ischemia from true remote ischemia ?*

Many times reciprocal changes may simply indicate extensive nature of the index inferior MI.Simply indicate a multi vessel disease.It could imply the IRA is a critically occluded LCX and STEMI is actually an infero -posterior STEMI.Pure electrical phenomenon (Referred to as reciprocal changes)*.ST segment depression is a fairly common observation in anterior precardial leads.