Right ventricular myocardial infarction symptoms and diagnosis by electrocardiogram

1. The new engl and jour nal of medicine
n engl j med 374;9 nejm.org March 3, 2016872
Images in Clinical Medicine
A
61-year-old man with a personal history of smoking and a fam-
ily history of coronary artery disease presented with what he described as
a squeezing pain in the left side of his chest that woke him from sleep. He
also had associated dizziness and diaphoresis. His heart rate was 85 beats per
minute, and he was hypotensive (blood pressure, 90/60 mm Hg). An initial electro-
cardiogram (ECG) showed a normal sinus rhythm, with ST-segment elevation in
leads II, III, aVF, and V1
(Panel A). Right ventricular infarction was suspected be-
cause of ST-segment elevation in V1
. ECG with precordial leads on the right side
was performed and showed 2:1 atrioventricular block and ST-segment elevation in
leads rV3
through rV6
, which confirmed ST-segment elevation myocardial infarc-
tion of the inferior wall, with involvement of the right ventricle (Panel B). Intrave-
nous fluids were administered, and a temporary transvenous pacing wire was
placed. Coronary angiography revealed a right coronary artery with 100% occlu-
sion proximal to the right ventricular branch (Panel C, arrow). Percutaneous coro-
nary intervention was performed, and flow to the right coronary artery (Panel D,
black arrow) and the right ventricular branch (Panel D, white arrow) was restored.
With adequate fluid resuscitation and the restoration of flow in the blocked artery,
the patient’s hemodynamic status improved, and the temporary pacing wire was
removed the next day. Subsequent echocardiography revealed normal left ventricu-
lar systolic function and mild right ventricular dysfunction.
DOI: 10.1056/NEJMicm1504379
Copyright © 2016 Massachusetts Medical Society.
Vinod Namana, M.D., M.P.H
Ram Balasubramanian, M.D.
Maimonides Medical Center
New York, NY
vnamana@maimonidesmed.org
A
I
II
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
I
II
III
aVR
aVL
aVF
rV1
rV2
rV3
rV4
rV5
rV6
B
C D
Lindsey R. Baden, M.D., Editor
Right Ventricular Infarction
The New England Journal of Medicine
Downloaded from nejm.org on March 2, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.