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JAMA Cardiology Clinical Challenge
September 2016

A 71-Year-Old Man With Complicated Myocardial Infarction

Author Affiliations
  • 1Department of Cardiology, Maimonides Medical Center, Brooklyn, New York
JAMA Cardiol. 2016;1(6):735-736. doi:10.1001/jamacardio.2016.1263

A 71-year-old man with a history of heart failure due to nonischemic cardiomyopathy, a left ventricular ejection fraction of less than 20%, hypertension, atrial fibrillation, and type 2 diabetes presented with substernal chest pressure of 1-hour duration, radiating to his left arm and occurring at rest. The electrocardiogram (ECG) at presentation revealed atrial fibrillation: concave upward ST-segment elevations of more than 1 mm in the inferior leads, more prominent in lead III than lead II, along with reciprocal ST-segment depressions in the anterior precordial leads. This was suggestive of an acute inferoposterior myocardial infarction (MI), likely from complete occlusion of the right coronary artery (RCA). The coronary angiogram (Figure 1A) confirmed this finding. The left main, the left anterior descending, and the left circumflex coronary arteries were normal. A percutaneous coronary intervention (PCI) of the mid-RCA occlusion just distal to the right ventricular branch was performed. After the PCI, the chest pain resolved, but the patient’s blood pressure was 90/60 mm Hg. Another ECG (Figure 1B) demonstrated resolution of the ST-segment elevations in the inferior leads with a new rSR′ pattern with concave upward ST-segment elevations in leads V1 to V3.