A 65-year-old man with STEMI undergoes primary PCI. After stenting the LAD, his BP drops to 80/50 mmHg, HR is 50 bpm, JVP is elevated, and clear lung fields are noted. ECG shows ST elevation in leads II, III, aVF and ST depression in V1–V3. Which additional territory is most likely infarcted?
- A Left anterior descending artery territory (anterior wall)
- B Circumflex artery territory (lateral wall)
- C Right ventricular infarction from RCA occlusion ✓
- D Left main coronary artery involvement
Correct answer: C. Right ventricular infarction from RCA occlusion
Explanation
ST elevation in leads II, III, aVF indicates inferior STEMI from RCA occlusion. ST depression in V1–V3 can represent a posterior extension or reciprocal changes. The clinical triad of hypotension, elevated JVP, and clear lung fields (Kussmaul's triad) in the setting of inferior STEMI is classic for right ventricular infarction, which occurs in up to 40% of inferior STEMIs. Treatment requires fluid loading and avoidance of nitrates and diuretics to maintain RV preload.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.