Medical Minute Recap: Right Sided EKG

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November 10, 2015 by dailybolusoflr

By: Erin Kane, MD

How do you know you need one?

  • All inferior STEMIs should have a right-sided EKG done (at least V4R)
  • Two clues in inferior STEMI that there is RV infarction:
    • ST segment elevation in lead V1
    • ST elevation in lead III>lead II
  • RV infarction is associated with hypotension (preload sensitive)

What is the relevant anatomy?

  • RV infarction is associated with 40% of inferior infarctions
  • May complicate some anterior infarctions
  • Rarely isolated phenomenon 
  • Affected vessels: usually RCA proximal to right ventricular marginal branches
  • Less commonly circumflex 

How do you place the leads to get it?

  • Record V4R for all inferior STEMIs – most sensitive 
  • V4R electrode is placed over right fifth intercostal space in mid-clavicular line

How do you read it?

  • ST elevation in V4R has sensitivity of 88% for diagnosing RV MI (78% specificity, diagnostic accuracy 83%)

Quick review:
Anatomical relationship of leads

  • Inferior wall – Leads II, III, and aVF
  • Anterior wall – leads V1 to V4
  • Lateral wall – Leads I, aVL, V5, V6

Non-standard leads

  • Posterior wall – Leads V7 to V9
  • Right ventricle – Right sided chest leads V1R to V6R


2. Mattu A, Brady W. ECGs for the Emergency Physician 1, BMJ Books 2003.
3. Morris F and WJ Brady. ABC of clinical electrocardiography: Acute myocardial infarction—Part I. BMJ 2002; 324: 831
4. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition

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