This 77-year-old woman had a myocardial infarct 9 years ago. She made a good recovery and was stable until 1 day before admission, when she developed severe crushing anterior chest pain at about 7 PM. Pain continued through the night, associated with nausea, vomiting and profuse perspiration. She called for help in the morning and is brought to the hospital by ambulance:

• Atrial fibrillation with rapid ventricular response (123/min)
• Acute inferior infarction
• Marked ST depression in V2, possible posterior injury pattern
• Possible anterior infarction (Q wave lead V4), age undetermined

In the Emergency Department the patient complained of severe pain across the anterior chest and dyspnea. Her blood pressure was 80/60. Her chest was clear. The jugular venous pressure was elevated to the angle of jaw. There was a positive Kussmaul’s sign. On palpation, the left ventricular impulse was displaced to the left. There was no right ventricular heave. An ECG was recorded, with the right chest leads (V2,V1, V2R-V6R)

• The right chest leads have been recorded
• Atrial fibrillation with rapid ventricular response
• Acute inferior infarct
• ST elevation from V2R to V6R, acute right ventricular infarction. Marked ST depression in V2 (noted in the previous tracing), suggestive of posterior wall injury

Comment: The clinical findings and the ECG abnormalities in the right chest leads are in keeping with acute right ventricular infarction. After admission to the CCU the patient became progressively hypotensive despite therapy. The echocardiogram showed severe left ventricular dysfunction, right ventricular enlargement and diffuse right ventricular hypokinesis. There was significant tricuspid regurgitation, but no mitral regurgitation. There was no evidence for papillary muscle rupture or pericardial effusion. 3 hours after admission the patient developed complete heart block and became pulseless. Resuscitation attempts failed.