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ECG Findings

  • Any ST elevation > 0.5 mm (0.05 mV) in right-sided leads (V1R-V6R).

  • Simultaneous ST elevation in lead V1 with ST-depression in lead V2 strongly suggests right ventricular (RV) myocardial infarction (MI).

  • Often associated with inferior MI and/or posterior MI.

Pearls

  1. ECG changes of RV MI are subtle and easily missed. Obtain a right-sided ECG in any patient with inferior STEMI or in a patient with a significant hypotensive response to nitrates.

  2. A right-sided ECG is obtained by placing right-sided V leads, with V1-V6 in mirror-image locations on the right side of the chest. The ECG leads are then marked V1R-V6R. Alternatively, V1 and V2 leads can be placed in their usual position with leads V3-V6 placed in mirror image (then V3R-V6R). V4R is the most sensitive lead.

  3. The right ventricle is very preload dependent. As such, the administration of nitroglycerin or diuretics in the presence of acute RV infarction can precipitate profound hypotension. Avoid any preload-reducing medications in these patients and give fluids liberally to maintain blood pressure as long as the lungs remain clear. Treat hypotension in a patient with acute RV MI aggressively with fluids.

FIGURE 23.4A

Right Ventricular Myocardial Infarction. This ECG was obtained with right-sided lead placement. (ECG contributor: Thomas Bottoni, MD.)

FIGURE 23.4B

ST elevation in V4R and V5R (arrows), with the V4 and V5 leads placed in their mirror-image locations on the right side of the chest. Any ST elevation seen in the right-sided precordial leads is significant.

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