Tombstone ST Segment Elevation in Double Vessel Coronary Artery Disease

Yutthapong Temtanakitpaisan, Yutthapong Temtanakitpaisan, Renee Dallasen, Craig Smith
2015 J Cardiovasc Dis Diagn   unpublished
Discussion ST segment elevation in leads V1-V3 is characteristic of LAD disease but has also been described in RCA occlusions [1,2]. When the RCA is dominant and gives rise to the posterior descending artery supplying the inferior wall and ventricular septum, occlusions proximal to the acute marginal branch cause both inferior wall and right ventricular infarcts. ECG typically demonstrates evidence of inferior injury, but electrocardiographic evidence of right ventricular infarction is
more » ... arction is suppressed by dominant electrical forces of simultaneous left ventricular inferoposterior injury [3,4]. In contrast, when a non-dominant RCA occlusion occurs in the absence of other native coronary artery disease, ST segment elevation in the anterior chest leads can be present due to absence of left ventricular injury altering electrical forces [2]. Our case demonstrates an isolated right ventricular injury from a lesion in the acute marginal branch of the RCA with no left Abstract We describe a 66 year-old male who presented with chest pain and ST segment elevation in the anterior leads. The typical culprit lesion is in the left anterior descending artery (LAD). However, concomitant lesions in the other coronary arteries may make an accurate diagnosis of the actual "culprit lesion" more challenging. Understanding the electrical basis of electrocardiograms can provide important clues in identifying and treating the true lesion. Figure 1: ECG demonstrates tombstone ST elevation in lead V2-V4.