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Diagnostics
a
Department of Emergency Medicine, University of Virginia, PO Box 800699, Charlottesville, VA 22908, USA
b
Department of Emergency Medicine, University of Maryland, Baltimore, MD 21201, USA
Abstract Right ventricular (RV) myocardial infarction most often occurs in the setting of inferior wall
myocardial infarction. Right ventricular infarction complicates approximately 25% (range, 20%-60%)
of inferior acute myocardial infarction; it is uncommon to quite rare in anterior and lateral wall acute
myocardial infarction. With infarction of the RV, the RV will fail. As such, left ventricular filling
pressures are entirely dependent upon the patient’s preload; with significant reductions in the preload,
hypotension likely results (this hypotension may be worsened by nitroglycerin and morphine). The
clinical presentation, in the setting of an ST-elevation myocardial infarction (STEMI) of the inferior
wall, involves hypotension, jugular venous distension, and the following electrocardiographic
findings: ST-segment elevation of greatest magnitude in lead III (compared with leads II and aVF),
ST-segment elevation in lead V1, and/or ST-segment elevation in right chest leads (RV1 through RV6).
Therapy, in addition to appropriate management for STEMI, relies largely on enhancing the preload
with intravenous fluid and judicious use of vasodilator medications. Patients with inferior wall STEMI
with RV infarction have a markedly worse prognosis (both acute cardiovascular complications and
death) compared with patients with isolated inferior wall STEMI.
D 2005 Published by Elsevier Inc.
Fig. 1 A, Twelve-lead ECG with ST-segment elevation in the inferior leads. Note that the most significant degree of ST-segment elevation
is in lead III. These findings are consistent with an inferior wall AMI with RV infarction. Also, ST-segment depression with prominent
T waves is seen in V1 through V3, consistent with posterior wall AMI. B, Three additional ECG leads, RV4 (RV) and V8 and V9 (posterior
wall), confirm the findings on the 12-lead ECG: ST-segment elevation in leads V8 and V9 confirm posterior wall AMI; similar ST-segment
elevation in lead RV4 supports RV infarction.
Fig. 2 A, Twelve-lead ECG with ST-segment elevation in leads II, III, and aVF, consistent with inferior wall AMI. Note that the degree of
ST-segment elevation is of greatest magnitude in lead III, consistent with an RV infarction. B, Right-sided ECG leads demonstrating
ST-segment elevation in leads RV2 through RV6.
796 S. Moye et al.
Fig. 5 Electrocardiogram in a patient with inferior wall and RV AMI. Note the use of the entire array of right-sided leads RV1 through RV6.
Compare this entire array with the single lead RV4 that demonstrates similar ST-segment elevation.
obscure the ST-segment elevation resulting from RV Recordings from leads placed on the right side of the
infarction in lead V1 as seen in the patient with the acute chest are much more sensitive and specific in detecting
inferoposterior MI with RV involvement (Figs. 1A and 7A). the changes of RV infarction (Fig. 3). The right-sided
In the setting of inferior wall AMI, if the degree of precordial electrodes are placed across the right side of the
ST-segment elevation is disproportionally greater in lead III chest in a mirror image of the standard left-sided leads and
relative to the other inferior leads, RV infarction is also are labeled V1R through V6R (Figs. 2, 5, and 7); RV1
suggested (Figs. 1A, 2, 6, and 7). If ST elevation in lead III through RV6 is another commonly used nomenclature for
is greater than lead II, the clinician should consider RV this lead distribution. The clinician may use either the
infarction. This disproportionate ST-segment elevation entire right-sided leads V1R through V6R or the single
results from the imaging axis, or lead orientation, of the lead V4R. Lead V4R (right fifth intercostal space
inferior leads. Lead III most directly images the RV (Fig. 3). midclavicular line) is the most useful lead for detecting
Fig. 6 Twelve-lead ECG with acute inferior wall AMI with RV infarction. Note the subtle ST-segment elevation in the leads II, III, and
aVF as well as lead V1.
798 S. Moye et al.
Fig. 7 A, Twelve-lead ECG with significant ST-segment elevation in the inferior (II, III, aVF) and lateral (V5 and V6) leads, consistent with
an inferolateral AMI. Note the ST segment depression, upright T wave, and prominent R wave in leads V1 through V3, consistent with an
acute posterior wall AMI and likely masking the RV infarction suggested by the greater degree of ST-segment elevation in lead III relative to
the other inferior leads. B, Subtle ST-segment elevation is seen in leads RV4 through RV6, suggestive of an RV AMI.
ST-segment elevation associated with RV infarction of RV infarction when compared with an entire comple-
(Figs. 1B, 4, and 5) and may be used solely in the ment of right chest leads [10]. ST-segment elevation from
evaluation of the possible RV infarction [10]. ST-segment RV infarction has a lesser amplitude than that seen in LV
elevation in lead V4R greater than 1.0 mm has been shown infarction, resulting from a smaller myocardial mass of the
to be a reliable marker of RV infarction [10]. Saw et al [11] RV. ST elevation of 1.0 mm or greater in V4R is
found that ST-segment elevation in lead V4R was more considered significant.
specific than the disproportionate lead III ST-segment Regardless of the ECG lead applied, the ST-segment
elevation (56% vs 78%, respectively); these authors, elevation that occurs in association with RV infarction is
however, preferred the disproportionate lead III ST-segment frequently quite subtle, reflecting the relatively small muscle
elevation because of its potential presence on all 12-lead mass of the RV; at other times, the ST-segment elevation is
ECGs. Robalino et al [12] found that ST-segment elevation quite prominent, similar in appearance to the ST-segment
in lead V4R greater than 1 mm has 87% specificity and changes seen in the standard 12 leads.
100% sensitivity when occlusion of the RCA is proximal to In addition to ST-segment elevation in the inferior leads,
the first ventricular branch. RV AMI is suggested by sinus bradycardia and AV node
Right-sided precordial leads are mirror images of the block. Proximal RCA occlusion endangers not only the RV
normal precordial leads. Lead V4R has shown similar rates ventricular branches but also the AV nodal artery.
The electrocardiogram in right ventricular myocardial infarction 799
Recognition of RV infarction is important for clinical [2] Cohn JN, Guiha NH, Broder MI, et al. Right ventricular infarction:
treatment of AMI. Because RV infarction is often associated clinical and hemodynamic features. Am J Cardiol 1974;44:209 - 14.
[3] Horan LG, Flowers NC. Right ventricular infarction: specific require-
with inferior wall infarction, a larger portion of myocardium ments of management. Am Fam Physician 1999;60:1727 - 34.
is endangered. This relatively large infarction increases the [4] Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med
urgency of reperfusion by thrombolytic agents, angioplasty, 1994;330:1211 - 7.
or coronary artery bypass graft. Impairment of RV function [5] Horan LG, Flowers NC, Havelda CJ. Relation between right
may lead to a deleterious drop in LV preload and, ventricular mass and cavity size: an analysis of 1500 human hearts.
Circulation 1981;64:135 - 8.
subsequently, a drop in cardiac output. This preload [6] Isner JM, Roberts WC. Right ventricular infarction complicating left
reduction may result in hypotension or shock. Whereas LV ventricular infarction secondary to coronary artery disease. Frequency,
dysfunction may result in congestive heart failure requiring location, associated findings and significance from analysis of
diuretics and fluid removal, RV dysfunction may require 236 necropsy patients with acute or healed myocardial infarction.
aggressive IV fluid therapy. If aggressive fluid therapy does Am J Cardiol 1978;42:885 - 94.
[7] Lopez-Sendon J, Coma-Canella I, Alcasena S, Seonane J, Gamallo C.
not satisfactorily improve hypotension, the use of an Electrocardiographic findings in acute right ventricular infarction:
inotrope such as dobutamine may be indicated. Atropine sensitivity and specificity of electrocardiographic alterations in right
may be used for bradycardia and pacing for AV block. precordial leads V4R, V3R, V1, V2 and V3. J Am Coll Cardiol
1985;6:1273 - 9.
[8] Anderson HR, Falk E, Nielsen D. Right ventricular infarction;
frequency, size and topography in coronary artery disease: a
4. Conclusion prospective study comprising 107 consecutive autopsies from a
coronary care unit. J Am Coll Cardiol 1987;10:1223 - 32.
Identification of RV infarction is important for the [9] Zehender M, Kasper W, Kauder E, et al. Eligibility for and benefit of
clinician. It has immediate clinical implications and serves thrombolytic therapy in inferior wall myocardial infarction: focus on
as a predictor for morbidity and mortality. Simple ECG the prognostic importance of right ventricular infarction. J Am Coll
methods can be used to predict the presence of an RV Cardiol 1994;24:362 - 9.
[10] Somers MP, Brady WJ, Bateman DC, Mattu A, Perron AD.
infarct. The clinician should be suspicious of an RV infarct
Additional electrocardiographic leads in the ED chest pain patient:
anytime an inferior wall infarction is present. Management right ventricular and posterior leads. Am J Emerg Med 2003;21(7):
of an RV infarction includes volume loading, reperfusion, 563 - 73.
rate control, and inotropic support. Right ventricular [11] Saw J, Davies C, Fung A, Spinelli JJ, Jue J. Value of ST elevation in
infarctions can be detected with simple ECG tests; the lead III greater than lead II in inferior wall acute myocardial infarction
for predicting in-hospital mortality and diagnosing right ventricular
clinician can then alter therapy accordingly.
infarction. Am J Cardiol 2001;87(4):448 - 50.
[12] Robalino BD, Whitlow PL, Underwood DA, et al. Electrocardio-
graphic manifestations of right ventricular infarction. Am Heart J
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