Right ventricular infarction – Part III

Let’s take a look at another case.

This was one of the first ECGs ever transmitted to my local receiving hospital on the Lifenet Receiving Station. It was definitely the first STEMI.

The data quality of the first 12 lead ECG wasn’t the greatest. This is the second ECG, with lead V4 in the position of V4R.

Unfortunately, I can’t seem to locate the details of this case. All I remember is that it was a male patient with chest pain.

This is an interesting ECG for several reasons.

There is ST segment elevation in leads II, III, and aVF which suggests acute inferior STEMI. You can also make out ST segment elevation in leads V5 and V6.

But where are the reciprocal changes? Normally we’d expect to see something in leads I and aVL. In this case, we don’t even have so much as a flattening of the ST segment.

Very unusual indeed!

The only places I can see ECG changes that could be construed as reciprocal changes are in leads aVR and V1.

Is this a STEMI? I wouldn’t blame you if you gave serious consideration to another diagnosis like pericarditis.

It is a STEMI.

Let’s look at lead V4R. Do you see ST segment elevation?

No.

In fact, there appears to be about 1 mm of ST segment depression.

Is there right ventricular involvement?

No.

The culprit artery isn’t even the RCA. It’s the circumflex (LCX).

Take a look at the image to the right from an editorial in the New England Journal of Medicine by HJ Wellens.

You will note that lead V4R in this case looks almost identical to the third example, which indicates occlusion of the circumflex artery.

When I contacted the director of cardiovascular services at the hospital, he confirmed that the circumflex was 100% occluded.

If you remember your coronary anatomy from Part I, it’s the right coronary artery (RCA) that typically supplies the right atrium and right ventricle before reaching the inferior wall of the left ventricle.

In a minority of patients, the circumflex (LCX) supplies the inferior wall of the left ventricle. Occlusion of this artery generally does not threaten the right ventricle.

So what have we learned? Is it always necessary to check the right sided precordial leads in the setting of acute inferior STEMI? Or at least lead V4R? It certainly isn’t going to hurt. I won’t discourage it.

Consider this comment left by Shaggy in Part II.

I work in a busy ED and one day the medics brought in a hypotenisive patient with an inferior wall MI on their 12 lead. I asked the attending if she wanted me to do a 12 lead with V4R. Her answer which I heard from others was if it is inferior and hypotensive, consider it right sided and treat as such. However, after reading this post, I see the importance of checking the right side on a normotensive patient with an inferior MI. I am glad you are around. I just wish I didn’t have to keep reviewing your posts.

I tend to agree with the attending. I would simply include patients who are technically normotensive but on the low side of “normal” especially if they are bradycardic or “shocky” in appearance!

SoCal Medic alluded to another trick in a comment he left for Part I.

I have been taught two different ways, the first by obtaining V4R and evaluating that for ST Segment changes and the second by comparing Lead II to Lead III.

You will notice that in Part II, the ST segment elevation in lead III is > than the ST segment elevation in lead II. An examination of lead V4R confirms right ventricular involvement.

In this case, the ST segment elevation in lead II is > than the ST segment elevation in lead III. An examination of lead V4R confirms that there is not right ventricular involvement.

Is it really that simple? Actually, it is.

Consider this table from Eskola et al. How to Use ECG for Decision Support in the Catheterization Laboratory – Cases With Inferior ST Elevation Myocardial Infarction. Journal of Electrocardiography Vol 37 No. 4 October 2004.

See also:

Right ventricular infarction – Part I

Right ventricular infarction – Part II

Right ventricular infarction – Part III

Additional resources:

From the March 2008 issue of EMS Magazine:

Recognition and Treatment of Right Ventricular Myocardial Infarction
by Gene Gandy

12 Comments

  • Tazambo says:

    Hi Tom,I just noticed that your profile pictured changed again, that’s 2 new ones in as many weeks, isn’t it?I should really post my photo, it nice to see who’s actually posting.RegardsDave

  • Tom B says:

    Hi Dave,It’s 3 if you include the South Park icon I created at South Park Studio.I took it down after a couple of hours because it didn’t seem professional enough. :)I had the most recent picture taken yesterday for an interview I did with the EP Lab Digest.It should be published in the March 2009 issue.Tom

  • qatardad says:

    The simple rule I always teach is this:1. Any suprapubic complaint gets a routine 12 lead.2. Any inferior MI gets a V4R3. Any inferior MI gets fluid for Frank-Starling priming and we hold off on NTG and MS, or do a careful trial after a bolus (as you described) but obviously go ahead with ASA. Nice blog, BTW. I run paramedicine.com.Marc

  • Anonymous says:

    Hi Tom.Do you give boulus fluid, and hold in with nitro, to all pt with right ventricular infarction, even if they are normotensive ?Sorry for my bad english. /Jenny. Sweden.

  • Tom B says:

    qatardad (Marc) – Thanks for the comment! Sorry I missed it.Tom

  • Tom B says:

    Jenny – If the BP is on the low side of normal with inferior STEMI then I go ahead with a fluid bolus.At the very least I obtain IV access before the first trial dose of NTG!Tom

  • Anonymous says:

    How about posterior involment in RV infarction ? Should ST depression in V1-v3(v4) be a "heads up" for RV involment as well in as inferior infarctions? The RCA supports the posterior wall to, doesnt it ?Thanks again for a really nice blogg. Keep it up./Rookie

  • Tom B says:

    Rookie – The RCA often supplies the posterior wall through the posterior descending artery, but that's a distal branch of the RCA.It's a proximal occlusion of the RCA we're concerned with! I always look for the tell-tale ST segment depression in the right precordial leads with inferior ST elevation, but it's not my main tip-off that I'm dealing with RVI! I still feel the best evidence is STE in lead III > STE in lead II, although STE in V4R is also part of the puzzle (and let's not forget the physical exam).Tom

  • Hillis says:

    I know the article was posted around year but just i'd like to thanke you Tom for your great work .. I should admit in each case am learning and revising alot of information that i've unfortunately missed and still learning !!. The interpretation of ECG is so tricky !!Thanke you so much

  • Tom B says:

    My pleasure, Dr. Hillis! Thank you for reading my blog!

    Tom

  • muataz says:

    thank u Tom its really informative

  • Bill MacPherson says:

    This was excellent and this is what we need for more learning for all of us. When we work together as a team with our patients wellbeing in our insterest the outcome will be all positive. I have worked as an ED nurse for 25 years now I’m in med school and believe me as a physician if you don’t listen to the paramedics story and the nurses you are in BIG TROUBLE work together and respect all and learn two heads are better then on
    Thanks Bill (Canada)

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
87 YOM COMPLAINING OF CHEST DISCOMFORT AND DYSPNEA
CHF. 12-lead shows a sinus Tachycardia in the 120s with PACs, besides the anterior leads there's diffuse ST depression, the STE in the anterior leads can be explained by the LBBB, axis is good as well. I wish they posted the EtCO2 waveform so we could see but I'm assuming it's non-obstructive. The elevated EtCO2…
2014-08-30 08:08:22
Christopher Watford
“Bad heartburn” – 82 y.o. female without chest pain.
Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14
CB
57 Year Old Male–Chest Discomfort
Given what he was doing (paint fumes on ladder painting) I would first question if the pain is reproducable. Yes his ekg isn't normal but looks like old inferior MI. And he is hypertensive. 02 a must. Def. would give ASA. First would give morphine and see how his cp and bp are. If still…
2014-08-29 11:37:25

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