[Skip to Content]

Claim CME

Challenges in Clinical Electrocardiography

A Paradoxical ST-Segment Elevation Distribution Rendering a Challenging Prediction of the Culprit Vessel in Acute Myocardial Infarction

To identify the key insights or developments described in this article

1 Credit CME

JAMA Internal Medicine

Published Online: January 23, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Ruihai Zhou, MSc, MD, RPVI¹

Author Affiliations

¹Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill

Read article on JAMA Network

Read Case Claim CME Answer

A patient in their 50s, a current cigarette smoker with a history of hypertension but no known cardiac disease, presented with sudden-onset chest pain via emergency medical services (EMS). The patient was hypertensive with a systolic blood pressure of 220 mm Hg by EMS. On arrival at the emergency department, the patient was in acute distress due to ongoing chest pain. The patient was afebrile, heart rate was 72 bpm, respiration rate was 16 breaths per minute, and blood pressure was 153/97 mm Hg. The cardiopulmonary examination was overall unremarkable. The electrocardiograms (ECGs) obtained by EMS and in the emergency department showed ST-segment elevation (STE), up to 5 mm in amplitude, in leads V₁ through V₃ and horizontal/down sloping ST depression (STD) in leads V₄ through V₆. The diagnosis was STE myocardial infarction (STEMI). The patient was subsequently brought to the cardiac catheterization laboratory for emergency cardiac catheterization and coronary angiography as a code STEMI.

Claim CME

Please finish quiz first before checking answer.

Findings from ECGs were first correlated with angiographic findings in patients presenting with STEMI by studies in the 1980s. In the setting of STEMI, the STE is present in the leads with positive electrodes overlying the infarcted region, and the STE distribution pattern can be used to predict the culprit vessel. The STE reflects an ischemia-induced injury current derived from the electrical voltage gradient at the boundary between the ischemic and normal myocardium.¹

In the present case, the ECG showed dramatic STE in leads V₁ through V₃, which usually connotes anterior/anteroseptal infarction from proximal left anterior descending artery (LAD) occlusion.¹ In contrast to our initial belief, the culprit vessel turned out to be the nondominant RCA, and there was no significant obstruction in the left coronary arteries. Emergency revascularization of the RCA by PCI led to resolution of chest pain and normalization of precordial ST-segment deviation on ECG. The precordial STE was believed to result from the right ventricle (RV) ischemic injury due to proximal occlusion of the nondominant RCA and RV branches.

Sign in to take quiz and track your certificates

Buy This Activity

Article Information

Corresponding Author: Ruihai Zhou, MSc, MD, RPVI, Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, 160 Dental Cir, Campus Box 7075, Chapel Hill, NC 27599-7075 (ruihai_zhou@med.unc.edu).

Published Online: January 23, 2023. doi:10.1001/jamainternmed.2022.6088

Conflict of Interest Disclosures: None reported.

References

Wagner GS , Macfarlane P , Wellens H , et al; American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society; Endorsed by the International Society for Computerized Electrocardiology. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. J Am Coll Cardiol. 2009;53(11):1003-1011. doi:10.1016/j.jacc.2008.12.016 PubMed Google Scholar Crossref

Jim MH , On-On Chan A , Wong CP , et al. Clinical implications of precordial ST-segment elevation in acute inferoposterior myocardial infarction caused by proximal right coronary artery occlusion. Clin Cardiol. 2007;30(7):331-335. doi:10.1002/clc.20096 PubMed Google Scholar Crossref

Vavuranakis M , Drakopoulou M , Toutouzas K , Polychronis D , Stefanadis C . Right ventricular infarction mimicking anterior infarction. Ann Noninvasive Electrocardiol. 2006;11(2):194-197. doi:10.1111/j.1542-474X.2006.00101.x PubMed Google Scholar Crossref

Geft IL , Shah PK , Rodriguez L , et al. ST elevations in leads V₁ to V₅ may be caused by right coronary artery occlusion and acute right ventricular infarction. Am J Cardiol. 1984;53(8):991-996. doi:10.1016/0002-9149(84)90623-4 PubMed Google Scholar Crossref

Andersen HR , Falk E , Nielsen D . Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am Coll Cardiol. 1987;10(6):1223-1232. doi:10.1016/S0735-1097(87)80122-5 PubMed Google Scholar Crossref

Porter A , Herz I , Strasberg B . Isolated right ventricular infarction presenting as anterior wall myocardial infarction on electrocardiography. Clin Cardiol. 1997;20(11):971-973. doi:10.1002/clc.4960201115 PubMed Google Scholar Crossref

Sharma H , George S . Occlusion of the right ventricular wall branch of a recessive right coronary artery resulting in ventricular fibrillation and anterior ST-segment elevation—a case report. Front Cardiovasc Med. 2020;7:124. doi:10.3389/fcvm.2020.00124 PubMed Google Scholar Crossref

Eichhöfer J , Curzen N . Images in cardiovascular medicine: unexpected profound transient anterior ST elevation after occlusion of the conus branch of the right coronary artery during angioplasty. Circulation. 2005;111(9):e113-e114. doi:10.1161/01.CIR.0000157152.65623.23 PubMed Google Scholar Crossref

Cafri C , Orlov G , Weinstein JM , Kobal S , Ilia R . ST elevation in the anterior precordial leads during right ventricular infarction: lessons learned during primary coronary angioplasty—a case report. Angiology. 2001;52(6):417-420. doi:10.1177/000331970105200607 PubMed Google Scholar Crossref

Kida M , Morishita H , Yokoi H , et al. Precordial ST-segment elevation caused by right coronary artery occlusion. J Cardiol. 1987;17(3):455-464.PubMed Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.