To study the value of the electrocardiogram in diagnosing right ventricular involvement in acute inferior wall myocardial infarction, the electrocardiographic findings were analysed in 67 patients who had had scintigraphy to pinpoint the infarct. All 67 patients were consecutively admitted because of an acute inferior wall infarction. A 12 lead electrocardiogram with four additional right precordial leads (V3R, V4R, V5R, and V6R) was routinely recorded on admission and every eight hours thereafter for three consecutive days. Thirty-six to 72 hours after the onset of chest pain a 99mtechnetium pyrophosphate scintigraphy and a dynamic flow study were performed to detect right ventricular involvement, which was found in 29 of the 67 patients (43%). ST segment elevation > 1 mm in leads V3R, V4R, V5R, and V6R is a reliable sign of right ventricular involvement. ST segment elevation , 1 mm in lead V4R was found to have the greatest sensitivity (93%) and predictive accuracy (93%). The diagnostic value of a QS pattern in lead V3R and V4R or ST elevation > 1 mm in lead V1 was much lower. ST segment elevation in the right precordial leads was short lived, having disappeared within 10 hours after the onset of chest pain in half of our patients with right ventricular involvement. When electrocardiograms are recorded in patients with an acute inferior wall infarction within 10 hours after the onset of chest pain, additional right ventricular infarction can easily be diagnosed by recording lead V4R.

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Paroxysmal atrioventricular (AV) block was induced by exercise in an otherwise healthy young man. The only abnormalities demonstrated at comprehensive cardiac evaluation were: 1) angiographic systolic narrowing of the left anterior descending coronary artery, and 2) reversible radionuclide hypoperfusion of the septum during exercise. It is postulated that ischemia of the conduction system due to systolic milking of the left anterior descending coronary artery was responsible for the paroxysmal AV block in this patient.

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