V1: The most important lead in inferior STEMI

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V₁: The most important lead in inferior STEMI

Author(s)

Vijaiganesh Nagarajan, MD, MRCP, FACP

Donald A. Underwood, MD

Figure 1. The patient’s 12-lead electrocardiogram showed sinus rhythm at a rate of 70 beats per minute. ST-segment elevation involving leads II, III, and aVF (red arrows) suggested inferior myocardial infarction. Reciprocal ST-segment and T-wave changes were noted in leads I and aVL (black arrows). ST-segment elevation was also noted in precordial leads V1 and V2 (blue arrows), suggesting acute right ventricular infarction.

A 63-year-old woman with diabetes and hypertension presented with chest tightness that had begun 1 hour previously. Her blood pressure was 90/60 mm/Hg and her jugular venous pressure was elevated, but the physical examination was otherwise normal. Her electrocardiogram is shown in Figure 1.

Q: Which would be the most appropriate diagnosis?

Pericarditis
Acute inferior and right ventricular myocardial infarction
Anterior and inferior myocardial infarction
None of the above

A: The correct answer is acute inferior and right ventricular myocardial infarction.

Her electrocardiogram showed sinus rhythm and inferior ST-segment elevation myocardial infarction (STEMI) evidenced by ST-segment elevation in leads II, III, and aVF. Hemodynamic instability or ST-segment elevation of more than 1 mm in lead V₁ raises the suspicion of right ventricular myocardial infarction. In such patients, the American Heart Association guidelines recommend electrocardiography with right-sided precordial leads.¹

A 1-mm ST-segment elevation in the right precordial lead V₄R is one of the most predictive electrocardiographic findings in right ventricular infarction.² The electrocardiographic changes in this type of myocardial infarction may be transient and resolve within 10 hours in up to 48% of cases.³

Echocardiography can also be used to confirm the possibility of right ventricular infarction.

Figure 2. Electrocardiography with right-sided precordial leads showed more ST-segment elevation of greater than 1 mm in right-sided leads V3R and V4R (arrows), thus confirming right ventricular myocardial infarction.

Our patient therefore underwent electrocardiography with right-sided precordial leads, which showed ST-segment elevation of more than 1 mm in leads V₃R and V₄R, thus confirming right ventricular myocardial infarction (Figure 2).

Q: Which clinical condition can occur as a complication of right ventricular myocardial infarction?

Profound hypotension after nitrate administration
High-degree heart block
Atrial fibrillation
All of the above

A: All of the conditions can occur.

Right ventricular involvement is very common, noted in up to 50% of patients with acute inferior STEMI in postmortem studies.⁴ However, hemodynamically significant right ventricular dysfunction is much less common.

Intravenous volume loading with normal saline is one of the first steps in the management of hypotension associated with right ventricular infarction. Patients with significant bradycardia or a high degree of atrioventricular block may require pacing. Early reperfusion should be achieved, if possible. Heightened suspicion is critical to the early diagnosis of this condition, since the prognosis is much worse than for isolated inferior STEMI.⁴

Our patient was found to have right coronary artery disease requiring percutaneous coronary intervention.

References

Antman EM, Anbe DT, Armstrong PW, et al; American College of Cardiology. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110:e82–e292.
Robalino BD, Whitlow PL, Underwood DA, Salcedo EE. Electrocardiographic manifestations of right ventricular infarction. Am Heart J 1989; 118:138–144.
Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368–372.
Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981–988.

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Author and Disclosure Information

Vijaiganesh Nagarajan, MD, MRCP, FACP
Department of Hospital Medicine, Cleveland Clinic

Donald A. Underwood, MD
Department of Cardiovascular Medicine, Cleveland Clinic

Address: Vijaiganesh Nagarajan, MD, MRCP, FACP, Department of Hospital Medicine, M2 Annex, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail [email protected]

Issue

Cleveland Clinic Journal of Medicine - 79(10)

Publications

Cleveland Clinic Journal of Medicine

Topics

Cardiology

Page Number

682-683

Sections

The Clinical Picture

Author(s)

Vijaiganesh Nagarajan, MD, MRCP, FACP

Donald A. Underwood, MD

Author(s)

Vijaiganesh Nagarajan, MD, MRCP, FACP

Donald A. Underwood, MD

Author and Disclosure Information

Vijaiganesh Nagarajan, MD, MRCP, FACP
Department of Hospital Medicine, Cleveland Clinic

Donald A. Underwood, MD
Department of Cardiovascular Medicine, Cleveland Clinic

Address: Vijaiganesh Nagarajan, MD, MRCP, FACP, Department of Hospital Medicine, M2 Annex, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail [email protected]

Author and Disclosure Information

Vijaiganesh Nagarajan, MD, MRCP, FACP
Department of Hospital Medicine, Cleveland Clinic

Donald A. Underwood, MD
Department of Cardiovascular Medicine, Cleveland Clinic

Address: Vijaiganesh Nagarajan, MD, MRCP, FACP, Department of Hospital Medicine, M2 Annex, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail [email protected]

Article PDF

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A 63-year-old woman with diabetes and hypertension presented with chest tightness that had begun 1 hour previously. Her blood pressure was 90/60 mm/Hg and her jugular venous pressure was elevated, but the physical examination was otherwise normal. Her electrocardiogram is shown in Figure 1.

Q: Which would be the most appropriate diagnosis?

Pericarditis
Acute inferior and right ventricular myocardial infarction
Anterior and inferior myocardial infarction
None of the above

A: The correct answer is acute inferior and right ventricular myocardial infarction.

Her electrocardiogram showed sinus rhythm and inferior ST-segment elevation myocardial infarction (STEMI) evidenced by ST-segment elevation in leads II, III, and aVF. Hemodynamic instability or ST-segment elevation of more than 1 mm in lead V₁ raises the suspicion of right ventricular myocardial infarction. In such patients, the American Heart Association guidelines recommend electrocardiography with right-sided precordial leads.¹

A 1-mm ST-segment elevation in the right precordial lead V₄R is one of the most predictive electrocardiographic findings in right ventricular infarction.² The electrocardiographic changes in this type of myocardial infarction may be transient and resolve within 10 hours in up to 48% of cases.³

Echocardiography can also be used to confirm the possibility of right ventricular infarction.

Our patient therefore underwent electrocardiography with right-sided precordial leads, which showed ST-segment elevation of more than 1 mm in leads V₃R and V₄R, thus confirming right ventricular myocardial infarction (Figure 2).

Q: Which clinical condition can occur as a complication of right ventricular myocardial infarction?

Profound hypotension after nitrate administration
High-degree heart block
Atrial fibrillation
All of the above

A: All of the conditions can occur.

Right ventricular involvement is very common, noted in up to 50% of patients with acute inferior STEMI in postmortem studies.⁴ However, hemodynamically significant right ventricular dysfunction is much less common.

Intravenous volume loading with normal saline is one of the first steps in the management of hypotension associated with right ventricular infarction. Patients with significant bradycardia or a high degree of atrioventricular block may require pacing. Early reperfusion should be achieved, if possible. Heightened suspicion is critical to the early diagnosis of this condition, since the prognosis is much worse than for isolated inferior STEMI.⁴

Our patient was found to have right coronary artery disease requiring percutaneous coronary intervention.

A 63-year-old woman with diabetes and hypertension presented with chest tightness that had begun 1 hour previously. Her blood pressure was 90/60 mm/Hg and her jugular venous pressure was elevated, but the physical examination was otherwise normal. Her electrocardiogram is shown in Figure 1.

Q: Which would be the most appropriate diagnosis?

Pericarditis
Acute inferior and right ventricular myocardial infarction
Anterior and inferior myocardial infarction
None of the above

A: The correct answer is acute inferior and right ventricular myocardial infarction.

Her electrocardiogram showed sinus rhythm and inferior ST-segment elevation myocardial infarction (STEMI) evidenced by ST-segment elevation in leads II, III, and aVF. Hemodynamic instability or ST-segment elevation of more than 1 mm in lead V₁ raises the suspicion of right ventricular myocardial infarction. In such patients, the American Heart Association guidelines recommend electrocardiography with right-sided precordial leads.¹

A 1-mm ST-segment elevation in the right precordial lead V₄R is one of the most predictive electrocardiographic findings in right ventricular infarction.² The electrocardiographic changes in this type of myocardial infarction may be transient and resolve within 10 hours in up to 48% of cases.³

Echocardiography can also be used to confirm the possibility of right ventricular infarction.

Our patient therefore underwent electrocardiography with right-sided precordial leads, which showed ST-segment elevation of more than 1 mm in leads V₃R and V₄R, thus confirming right ventricular myocardial infarction (Figure 2).

Q: Which clinical condition can occur as a complication of right ventricular myocardial infarction?

Profound hypotension after nitrate administration
High-degree heart block
Atrial fibrillation
All of the above

A: All of the conditions can occur.

Right ventricular involvement is very common, noted in up to 50% of patients with acute inferior STEMI in postmortem studies.⁴ However, hemodynamically significant right ventricular dysfunction is much less common.

Intravenous volume loading with normal saline is one of the first steps in the management of hypotension associated with right ventricular infarction. Patients with significant bradycardia or a high degree of atrioventricular block may require pacing. Early reperfusion should be achieved, if possible. Heightened suspicion is critical to the early diagnosis of this condition, since the prognosis is much worse than for isolated inferior STEMI.⁴

Our patient was found to have right coronary artery disease requiring percutaneous coronary intervention.

References

Antman EM, Anbe DT, Armstrong PW, et al; American College of Cardiology. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110:e82–e292.
Robalino BD, Whitlow PL, Underwood DA, Salcedo EE. Electrocardiographic manifestations of right ventricular infarction. Am Heart J 1989; 118:138–144.
Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368–372.
Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981–988.

References

Antman EM, Anbe DT, Armstrong PW, et al; American College of Cardiology. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110:e82–e292.
Robalino BD, Whitlow PL, Underwood DA, Salcedo EE. Electrocardiographic manifestations of right ventricular infarction. Am Heart J 1989; 118:138–144.
Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368–372.
Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981–988.