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Letter by Madias Regarding Article, "Cardiac Arrest With ST-Segment-Elevation in V1 and V2: Differential Diagnosis".

October 30, 2018 2069 John E. Madias, MD To the Editor: I read with interest the ECG challenge by Arroyo Rivera et al,1 reporting on a 58-year-old male patient who experienced an acute right ventricular (RV) myocardial infarction (MI), complicated by out-of-hospital cardiac arrest attributable to ventricular fibrillation. The authors discuss comprehensively the ECG findings that point to the diagnosis of a RV MI, and not an anterior MI. Two additional ECG findings could be added to their otherwise very convincing analysis. In Figure 1 of their article,1 ST-elevation (+ST) in lead III is larger than in lead II, indicating that the +ST vector is >90°, and thus pointing to the RV,2 and +ST is larger in lead V1 than in lead V2, because of greater proximity to the RV of the locus of V1 than V2: both of these findings suffice to diagnose RV MI,2 and to get prompted to record V3R and V4R right chest ECG leads for further confirmation. Knowledge of these 2 additional insights is important in the light of failure among contemporary physicians to record additional right chest leads, and the old controversy whether such leads are really necessary.2–5 Also the fact that there were no +STs in the V3–V6 precordial leads, and very mild +STs in leads II and III, suggest that one dealt mainly with a RV MI, and a possible small inferior MI, attributable to proximal occlusion of the right coronary artery, before the takeoff of the acute marginal RV branch, and certainly not with an anterior MI, attributable to an occlusion of the left anterior descending coronary artery. Thus the precise diagnosis could have been certain,2 before the performance of the emergent coronary angiography. It would be of interest to the readers to know how this patient fares currently, considering that he has experienced a massive permanent damage of his RV, attributable to the proximal occlusion of his nondominant right coronary artery.