A 62-year-old man presents with syncope and hypotension after an acute inferior STEMI. Jugular venous pulse shows prominent 'a' waves, lungs are clear, and ECG shows ST elevation in V4R. Which coronary artery occlusion is most likely responsible?

• A Left anterior descending artery distal to the first diagonal
• B Left main coronary artery
• C Left circumflex artery at the obtuse marginal origin
• D Right coronary artery proximal to the right ventricular branches ✓

Explanation

Right ventricular infarction complicates roughly one third of inferior STEMIs and results from proximal right coronary artery occlusion before the right ventricular marginal branches are given off. The clinical triad is hypotension, clear lung fields, and raised JVP, with ST elevation in V4R being the most sensitive ECG finding. Distal LAD occlusion affects the apex and anterior wall, circumflex occlusion gives lateral involvement, and left main occlusion is usually fatal.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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