Wrong Reason for the Right Report
Report:
Sinus tachycardia 128/min
Third degree AV block
Junctional escape rhythm 38/min
Acute inferior and right ventricular infarction
(Right-sided V leads as labelled)
Atrial infarction
Comment:
The report followed a previous one, on a preceding ECG taken on the same day which indeed showed both inferior and anterior infarction (Fig 73a). It is understandable, psychologically, to have diagnosed “extensive anterior infarct” on the appearance of also infarctional right-sided chest leads. Or, repetition compulsion?
The patient was in cardiogenic shock from the extent of his infarction and the presence of right ventricular infarction and complete AV block. Atrial infarction (seen as PT segment elevation in 2 and aVF) did not help, either, but in view of the CHB its impact on the atrial transport would be of little moment.
In the tracing below (Fig 73a), the reciprocal ST segment depression in both 1 and aVL suggests the RCA as the culprit vessel. Depression in V1-2 means that the elevation in the remaining precordial leads is not – as it sometimes may be53 - an expression of right ventricular, rather than a separate anterior, infarction. It is likely that the acutely occluded RCA had been supplying distal LAD artery via collaterals.
The patient survived extensive support and interventions and did surprisingly well.
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