How To Spot Right Ventricular (RV) Infarction on ECG

Look at these two ECGs:

  
Second ECG with "Right sided" Chest leads:

What is your diagnosis? 
Can you spot Right ventricular infarction?

Explanation:

Its Inferior Wall Myocardial Infarction with Right Ventricular Infarction as seen on ECG with right sided chest leads.

How To Spot Right Ventricular Infarction?

Spotting Right ventricular infarction is important for management as you have to give lot of fluids and to avoid blood pressure lowering medications such as nitrates in these patients. There are three methods to spot RV Infarction, first is clinical, second method is indirect method on standard 12 lead ECG and at the last Direct (Confirmatory method) on ECG with "Right sided" chest leads.

1. Clinical:

2. Indirect Method:

3. Direct Method:

1. Clinical:

Classic clinical Triad of Right Ventricular Infarction includes Distended Neck Veins with Clear lung Fields & hypotension Other features include Kussmaul sign and Pulsus paradoxus.

2. Indirect Method:

ST segment elevation in V1 greater in magnitude as that in V2,

or ST segment elevation in V1  plus ST depression in V2  (= highly specific for RV MI)

Isoelectric ST segment in V1 associated with marked ST depression in V2.

3. Direct Method:

Right ventricular infarction is confirmed by the presence of ST elevation in the right-sided leads (V3R-V6R).

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