EKG and RVMI

Q: In acute Right Ventricular Myocardial Infarction (RVMI), which electrocardiogram (EKG) lead's ST-elevation has the highest sensitivity and specificity?

Answer: V4R

Patients with inferior-posterior ST-elevation MI mostly have RVMI, causing the classic triad of:

• hypotension
• elevated jugular venous pressure (JVP), and 
• clear lung fields

ST elevation >1 mm in lead V4R has> 90% sensitivity and specificity for scintigraphic evidence of RV infarction and 80% for echocardiographic evidence of RV dysfunction. A clinical pearl to remember is that the right-sided ST elevation is often transient, lasting less than 10 hours in 50% of patients with RV infarction.

#cardiology

References:

1. Watanabe S, Onuma J, Ishida R, Masuda R, Usui M. Clinical Significance of V4R ST-Segment Elevation on a Synthesized 18-Lead Electrocardiogram in Patients With Anterior ST-Segment Elevation Myocardial Infarction. Catheter Cardiovasc Interv. 2026 Jul;108(1):221-227. doi: 10.1002/ccd.70646. Epub 2026 Apr 26. PMID: 42036972.

2. Braat SH, Brugada P, de Zwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368.

3. Candell-Riera J, Figueras J, Valle V, et al. Right ventricular infarction: relationships between ST segment elevation in V4R and hemodynamic, scintigraphic, and echocardiographic findings in patients with acute inferior myocardial infarction. Am Heart J 1981; 101:281.