Right-Sided STEMI ECG Presentation

Standard ECG Findings

The European Society of Cardiology recommends recording right precordial leads (V3R and V4R) in all patients with inferior wall STEMI to identify concomitant right ventricular involvement, as ST elevation ≥0.1 mV in lead V4R is the key diagnostic finding for right ventricular infarction 1, 2
Right precordial leads (V3R and V4R) must be specifically recorded, as they are not part of the standard 12-lead ECG and directly overlie the right ventricular free wall 1, 2

Inferior wall ST elevation is present in approximately 76% of right ventricular STEMI cases, typically showing ST elevation in leads II, III, and aVF, according to the American Heart Association 3, 4
ST depression in leads I and aVL commonly accompanies inferior wall involvement, and ST depression in precordial leads V1-V3 may be present as reciprocal changes 3, 4

The American College of Cardiology recommends obtaining standard 12-lead ECG within 10 minutes of first medical contact and identifying any ST elevation in inferior leads (II, III, aVF) or anterior leads (V1-V3) 2, 3, 4
Immediately record right precordial leads V3R and V4R in all patients with inferior STEMI, as recommended by the European Society of Cardiology 1, 2

The European Society of Cardiology recommends proceeding directly to emergency coronary angiography without waiting for biomarker results when right ventricular STEMI is diagnosed, and reperfusion therapy must be initiated as soon as possible 1, 2, 5