Middle-aged patient presenting with chest pain and diaphoresis. BP dropped to 80/50 following sublingual nitrates.

Describe and interpret this ECG



Signs of inferior STEMI:

  • STE in inferior leads II, III, aVF
  • Reciprocal STD in lateral leads I, aVL, V6

Signs of associated right ventricular infarction:

  • STE in III > II
  • STE in V1-2

This patient also had STE in V4R, confirming the diagnosis of RV infarction:

  • RV infarction complicates 40% of inferior STEMIs
  • Suggestive features include:
    • ST elevation in V1, the only lead that looks directly at the RV
    • ST elevation in III > II, as lead III is more rightward facing
  • Diagnosis can be confirmed with right-sided leads
  • These patients are preload sensitive and may have an exaggerated hypotensive response to nitrates

Read more about diagnosing RV infarction and how to record the V4R lead

TOP 100 ECG Series

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner


  1. It seems to be an occlusion of a big dominant RCA with PDA rapping around the apex causing antero-inferior MI

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