□ LETTERS TO THE EDITOR □

ST-segment Elevation in V1-V3 in Patients with usually confirmed retrospectively) is the resolution of STE
Inferior STEMI: An Important Sign of Right without the development of Q waves in cases of RV infarc-
Ventricular Infarction tion (3). In these instances, a simple tool is to perform a
Key words: right ventricular infarction, inferior myocardial
infarction, culprit vessel PCI
(Intern Med 52: 1661, 2013)
(DOI: 10.2169/internalmedicine.52.0438)
To the Editor I read with great interest the article by
Kurisu and Kihara that described the occurrence of ST-
segment elevation (STE) in leads V1-V3 due to proximal
right coronary artery (RCA) occlusion (1). In the setting of
acute inferior ST-segment elevation myocardial infarction
(STEMI), the presence of STE in V1-V3 is a known sign
that should raise suspicion of a right ventricular (RV) infarc-
tion (2). However, this phenomenon is seldom present be-
cause the electrical current of injury from the left ventricle
inferior infarction dominates the RV electrical forces block-
ing the appearance of STE in these leads (3).
In patients with inferior STEMI, the presence of STE in
the anterior leads is either due to RV infarction or concomi-
tant anterior STEMI. There are two main features used to
distinguish between these conditions. First, in RV infarction,
there is a reduction in the amplitude of STE from leads V1
to V3 (i.e., the amplitude of STE is highest in V1 and de-
creases towards V3), unlike that observed in anterior
STEMI, where the amplitude of STE is lowest in V1 and in-
creases towards V3. Another distinguishing feature (which is
right-sided chest leads ECG looking for STE in lead V4R,
which is a powerful predictor of RV involvement. In the
presented case, the amplitude of STE was V1>V2>V3 (on
the admission ECG), and following reperfusion, the STE in
V1-V3 resolved without the development of Q waves (on
the ECG performed 16 hours later).
The presence of STE in lead III > lead II, ST-segment de-
pression in aVL > lead I and RV infarction suggest that the
RCA was the culprit vessel with a lesion proximal to the
RV marginal branch. Awareness of the culprit vessel may
provoke some cardiologists to target the RCA first (perform-
ing culprit vessel PCI rather than traditional catheterization),
which will reduce the artery-to-balloon time and save sev-
eral extra minutes during this very sensitive period for car-
diac myocytes.
The author states that he has no Conflict of Interest (COI).
Hesham R. Omar
References
1. Kurisu S, Kihara Y. Syncope and ST elevation in precordial leads.
Intern Med 52: 517, 2013.
2. Omar HR. Chest pain followed by sudden collapse. Cleve Clin J
Med 79: 110-112, 2012.
3. 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 53: 991-996, 1984.

Internal Medicine Department, Mercy Hospital and Medical Center, USA

Received for publication February 23, 2013; Accepted for publication March 13, 2013
Correspondence to Dr. Hesham R. Omar, hesham_omar2003@yahoo.com
Ⓒ 2013 The Japanese Society of Internal Medicine Journal Website: http://www.naika.or.jp/imonline/index.html

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