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Standard 12-lead ECG is a gold standard method in suspected Acute Coronary Syndromes (ACS) in patients presenting with acute chest pain. However, standard 12-lead ECG does not provide sufficient information in posterior wall and right ventricle wall ischemia detection. Additional leads (V3R-V5R, V7-V9) may enhance diagnostic accuracy with added sensitivity for ischemia detection. Especially when presentation is not typical or initial 12-lead ECG is negative, diagnostic inaccuracy may cause harmful delays. Proper ischemia detection may prevent myocardial damage or may shorten the time to PCI (percutaneous coronary intervention) indication.

Even though recommended by guidelines additional workload, patient immobility and a lack of confidence often make the 18-lead ECG absent in a
routine patient care. Nihon Kohden developed a synthesized 18-lead ECG (standard 12-lead ECG and 6 synthesized leads) that can help to overcome
those obstacles.

The clinical significance of 18-lead ECG with synthesized right-sided and posterior leads (V3R-V5R, V7-V9) for the rapid diagnosis of STEMI
within 10 minutes of the emergency department (ED) arrival is presented by several studies. Especially for the early detection of right ventricular
infarction the synthesized 18-lead ECG has been judged valuable. A preliminary evaluation in Europe with Caucasian population confirmed the previous study results on Asian population that the synthesized 18-lead ECG is an effective ischemia triage tool.

The accuracy of the ST segment of the synthesized ECG has been considered to be highly reliable and is useful to identify the area at risk.