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Right ventricular M.I.

Inferior Wall M.I. With Right Ventricular M.I.

Sat, 10/28/2017 - 18:36 -- Dawn

This ECG was recorded from a 75-year-old man with substernal chest pain and diaphoresis.  It shows a pretty classic picture of acute inferior wall M.I. The second ECG is a repeat tracing with the V4 wire moved to the V4 Right position, and it is positive for right ventricular M.I.  The patient was found to have a 100% occlusion of the right coronary artery, which was opened and stented in the cath lab.

There are several other examples of IWMI with RVMI in our archives, so we will confine this commentary to the ECG signs that make these tracings so typical of right coronary artery occlusion. Once you are familiar with the typical pattern of IWMI / RVMI, it is easy to see, even when the ST elevation is subtle (as this one certainly is NOT).

Signs of IWMI in these ECGs are

·         ST elevation in inferior leads II, III and aVF.

·         Reciprocal ST depression in leads I and aVL. 

Signs of RVMI in these ECGs are:

·         ST elevation in V4 right.

·         ST elevation in V1 without ST elevation in V2.

Acute Inferior Wall M.I. With Right Ventricular M.I. and Atrial Fibrillation

Tue, 05/19/2015 - 11:10 -- Dawn

This 31-year-old man presented to the Emergency Dept. complaining of chest pain, shortness of breath, and nausea. His heart rate on admission was 120 - 130 bpm and irregular, and the monitor showed atrial fibrillation. His rate slowed with the administration of diltiazem. His 12-lead ECG shows the classic ST elevation of inferior wall M.I. in Leads II, III, and aVF. This patient also had JVD, bibasilar rales, orthopnea, and exertional dyspnea, signs of CHF. He had no history of acute M.I., CHF, or atrial fibrillation. He offered no history of drug use or medications.

This ECG is very useful for the basic student, in that the ST elevations are readily seen, and the atrial fib is definitely irregularly-irregular. For the more advanced student, the ST depression in V2 indicates posterior wall injury, while the flat ST segment in V1 indicates a possible right ventricular M.I.  While the posterior wall is trying to depress the ST segment, the right ventricle is trying to elevate it, resulting in flattening. Also, Lead III has a greater STE than Lead II, which has been shown to be a reliable indicator of RV infarction.  This should be confirmed with a V4 right, or all chest leads done on the right side. Right ventricular injury has been shown to increase mortality, and it also requires different management of hemodynamics.

Teaching Series 112213 Inferior-posterior Wall M.I. With Right Ventricular M.I.

Tue, 12/03/2013 - 21:21 -- Dawn

This series of ECGs was taken during ambulance transport of a 67 year old man with chest pain.  Earlier the same week, this man had been discharged from the hospital after having a cardiac cath, angioplasty, and stents. He was discharged the next day.  The patient stated that, until that hospital admission, he was healthy, athletic, and had no significant medical history.  He is currently taking a statin, atenolol, and "one of the new blood thinners" - he didn't know the name.

 ECG No. 3 is the first one shown here, taken at almost 39 minutes after midnight.  The patient was complaining of chest pain of 8 on a 1-10 scale.  His skin was pale, cool, and clammy.  The ECG shows acute inferior-posterior M.I., with ST elevation in II, III, and aVF and reciprocal ST depression in V2, and V3.  V1 would normally be depressed in posterior extension of an inferior wall M.I. - unless the right ventricle is also infarcted.  The message from the right ventricle to V1 would be "elevate", countering the message from the posterior wall, "depress".   The rhythm is sinus with ventricular bigeminy.  The rescue crew notified the hospital of a "STEMI Alert". The patient received I.V., O2,  nitroglycerin spray and paste, as well as aspirin.  The patient's BP was 144/92.

ECG No. 4 was taken at 12:41 a.m.  It shows a change in P waves probably reflecting a low atrial focus.  The patient has a slow underlying rhythm with ventricular bigeminy that is probably multifocal.  It is very hard to determine multifocal PVCs when there is no concurrent rhythm strip, but this is a three-channel ECG machine, and the rhythm strips are run separately from the 12-lead.  There are runs of V Tach toward the end of the ECG, and this is not a good sign in a patient with ST elevation.  In some cases, the V Tach can become persistent, in others it is transient.  The ST elevation and reciprocal depressions are still evident.

ECG No. 5, taken at 12:49 a.m., shows further development of the ST segments, and the classic "domed" shape of STEMI.  In addition, a pathological Q wave has appeared in Lead III, possibly indicating permanent damage from this M.I.  In this ECG, the paramedics have moved the V4 wire to the V4 Right position to better view the right ventricle.  V4 Right is slightly elevated, and definitely dome-shaped, like a frown.  This is an indication that the RV is injured, and medications that lower BP (especially nitroglycerin) should be avoided in the pre-hospital setting because of the danger of loss of preload of the RV and sudden drop in cardiac output. The patient's BP at this time was 138/85.

Inferior Wall M.I. With Right Ventricular M.I.

Sat, 01/12/2013 - 20:49 -- Dawn

This week's ECG of the Week is from an elderly woman who suffered an acute occlusion of the right coronary artery.  The ECG clearly shows ST elevation in leads II, III, and aVF, indicating inferior wall injury.  In this case, this ECG was obtained in the field by paramedics, and was the second ECG done on this patient. For this tracing, the paramedics obtained V3 and V4 on the right side to better view the right ventricle. V3 and V4 right clearly show ST elevation as well, indicating RVMI.  The slight coving and elevation observable in V1 is also an indication of RV involvement, and the ST depression in V2 indicates posterior wall injury.  All of this results from a proximal lesion of the RCA in this patient.  Such a lesion carries a high morbidity and mortality.

Taking the time to obtain a right ventricular lead is controversial in some settings.  Some believe the patient's hemodynamic condition should be treated, regardless of the presence or absence of ST elevation in right chest leads.  Others find it very helpful to know that the right ventricle is affected.  In this case, paramedics in this community have a protocol to avoid the use of nitroglycerine in RVMI patients, even when the BP is adequate.  So, for them, it is important to have the information gathered from V Right leads.

The rhythm here is interesting, as well, and not at all uncommon for IWMI patients.  The baseline artifact makes it a bit difficult to march out all the P waves, but it appears they are sinus P waves that are slightly irregular at a rate of 52 to 54.  The PR intervals appear to be progressively prolonging, but there is no "grouped beating" observable on this short strip.  A lack of a concurrent Lead II rhythm strip also makes it difficult to determine the rhythm, as Lead II does have very visible P waves, and would be helpful.  The regularity of the narrow complex bradycardia points to a junctional escape rhythm, which would make this a third-degree AVB at the AV node level, which is very common with IWMI.  What do you think?

This month's strip from Jason Roediger's ECG Challenge blogpost is a nice complement to the strip presented here.  His is much clearer, and has a Lead II rhythm strip.  Do you think these ECGs show the same rhythm, or two different rhythms?

For an excellent discussion of "AV Dissociation" vs. "AV Block", go to Christopher Watford's Ask the Expert post.  Thanks very much to ECG Guru Sebastian Garay for this interesting ECG.

Inferior Wall M.I. with Right Ventricular M.I.

Sat, 02/11/2012 - 17:39 -- Dawn

These two ECGs are from a 57 year old man with chest pain. The initial ECG shows ST elevation in Leads II, III, and aVF - inferior wall STEMI. Reciprocal changes are as expected in I and aVL. Reciprocal ST depression also seen in V1 and V2 indicate probable posterior wall involvement. Not surprising since the inferior wall is simply the lower part of the posterior wall. The first ECG also shows the patient in sinus brady with junctional escape: AV dissociation. The sinus node is often affected in IWMI that is caused by right coronary artery occlusion. The second ECG shows a slight increase in the sinus rate, and a sinus bradycardia. A V4 right lead has been performed, clearly showing ST elevation, and indicating right ventricular M.I.



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