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Original Article

Right Ventricular Infarction as an Independent Predictor of Prognosis after Acute Inferior Myocardial Infarction

List of authors.
  • Manfred Zehender,
  • Wolfgang Kasper,
  • Elisabeth Kauder,
  • Martin Schonthaler,
  • Annette Geibel,
  • Manfred Olschewski,
  • and Hanjorg Just

Abstract

Background

Acute inferior myocardial infarction frequently involves the right ventricle. We hypothesized that right ventricular involvement, as diagnosed by ST-segment elevation in the right precordial lead V4R, may affect the prognosis of patients with inferior myocardial infarctions.

Methods

In 200 consecutive patients admitted to the hospital with acute inferior myocardial infarctions, we assessed the prevalence and diagnostic accuracy of ST-segment elevation in lead V4R (as compared with four other diagnostic procedures) to identify right ventricular involvement and its prognostic implications for in-hospital and long-term outcomes.

Results

The in-hospital mortality after inferior myocardial infarction was 19 percent, and major complications occurred in 47 percent of the patients. The presence of ST-segment elevation in lead V4R in 107 patients (54 percent) was highly predictive of right ventricular infarction (sensitivity, 88 percent; specificity, 78 percent; diagnostic accuracy, 83 percent), as compared with the other diagnostic procedures. The patients with ST-segment elevation in lead V4R had a higher in-hospital mortality rate (31 percent vs. 6 percent, P<0.001) and a higher incidence of major in-hospital complications (64 percent vs. 28 percent, P<0.001) than did those without ST elevation in V4R. Multiple logistic-regression analysis showed ST elevation in V4R to be independent of and superior to all other clinical variables available on admission for the prediction of in-hospital mortality (relative risk, 7.7; 95 percent confidence interval, 2.6 to 23) and major complications (relative risk, 4.7; 95 percent confidence interval, 2.4 to 9). The post-hospital course (follow-up, at least 1 year; mean follow-up, 37 months) was similar in patients with and in those without electrocardiographic evidence of right ventricular infarction.

Conclusions

Right ventricular involvement during acute inferior myocardial infarction can be accurately diagnosed by the presence of ST-segment elevation in lead V4R, a finding that is a strong, independent predictor of major complications and in-hospital mortality. Electrocardiographic assessment of right ventricular infarction should be routinely performed in all patients with acute inferior myocardial infarctions.

Introduction

Despite the initial observation of serious hemodynamic consequences of right ventricular infarction nearly two decades ago,1 this condition has received little clinical attention until recent years2-4. Postmortem studies revealed that there is right ventricular involvement in 19 to 51 percent of patients with acute inferior myocardial infarctions5-8. Right ventricular infarction contributes markedly to hemodynamic instability, atrioventricular conduction block, and in-hospital mortality in patients with inferior myocardial infarctions3,4,9-12. However, simple diagnostic criteria that can be routinely applied and shown to be of prognostic value remain to be identified2-4,13,14.

The diagnosis of right ventricular infarction can be made from the physical examination,3,15 echocardiography,3,15 first-pass16,17 or equilibrium radionuclide9,18 ventriculography, technetium pyrophosphate myocardial scanning,18,19 and hemodynamic measurements,3,15,20 but right precordial electrocardiography21-25 is the most readily available, simplest, and most objective of these techniques26. The presence of acute ST-segment elevation,13,21-31 Q waves, or both in the right precordial leads (V3R to V6R)13,24,29,32 was found to be highly reliable in the diagnosis of right ventricular infarction, as compared with the gold standard of hemodynamic assessment or autopsy3,26. A study by Andersen et al.27 suggested that ST-segment elevation in leads V3R through V6R is a useful marker of poor outcome after an inferior myocardial infarction. However, the prognostic effect of these criteria as compared with other clinical variables is uncertain.

In a prospective study of 200 consecutive patients with acute inferior myocardial infarctions, we evaluated in-hospital and long-term outcomes with regard to the presence or absence of right ventricular infarction, as indicated by ST-segment elevation in the right precordial lead V4R.

Methods

Patients

Table 1. Table 1. Clinical Characteristics and In-Hospital Outcomes in 200 Consecutive Patients with Acute Inferior Myocardial Infarctions.

From August 1985 through January 1990, we prospectively studied 200 consecutive and consenting patients who were admitted to our institution with acute inferior myocardial infarctions diagnosed by typical chest pain lasting for more than 30 minutes, ST-segment elevation of ≥ 0.1 mV in two or more of leads II, III, and aVF, and an increase in the serum creatine kinase level to more than twice the normal value (>140 U per liter) less than 24 hours after admission. Patients were included in the study if chest pain had begun less than 24 hours before admission (mean [±SD] duration of pain, 6.1 ±4.6 hours; range, 0.5 to 23). The clinical data on the patients are presented in Table 1.

We considered thrombolytic therapy for every patient who presented with chest pain that had begun no more than six hours earlier, who was 75 years old or less, and who did not have contraindications to thrombolysis (Table 1). Coronary balloon angioplasty was not routinely performed after thrombolytic therapy.

Diagnostic Evaluation

Standard 12-lead electrocardiograms (with leads I through III, aVR, aVL, aVF, and V1 through V6) and right precordial electrocardiograms (V3R through V6R) were recorded immediately after admission to the hospital. In the patients receiving thrombolytic therapy, electrocardiograms were obtained before the administration of the thrombolytic agent. The electrocardiograms were classified according to the Manhattan Code Criteria33. ST-segment deviations were assessed 0.04 second after the J point in all 16 leads. Three consecutive QRS complexes were measured with the PQ level used as the isoelectric line. ST-segment elevation of ≥ 0.1 mV in more than two leads of II, III, and aVF was considered to be an indicator of infarction. The presence or absence of abnormal Q waves ( ≥ 0.04 second) was separately noted in leads II, III, and aVF and in the right precordial leads. All analyses were performed by a cardiologist unaware of the clinical status of the patient. ST elevation of ≥ 0.1 mV in lead V4R was chosen for the prognostic analysis24,26-31. Other than ST-segment elevation in leads II, III, and aVF, no patient had ST-segment elevation in leads V1 through V3, 7 of 200 patients (4 percent) had ST-segment elevation in leads I, aVL, or both (none of 107 patients with ST-segment elevation in lead V4R, as compared with 7 of 93 patients without such elevation; P = 0.004), 44 of 200 patients (22 percent) had additional ST-segment elevation in leads V4 through V6 (25 of 107 patients vs. 19 of 93 patients, P = 0.73), and 46 of 200 patients (23 percent) had a tall R wave in leads V1 and V2 (26 of 107 patients vs. 20 of 93 patients, P = 0.74).

The diagnostic accuracy of ST-segment elevation in lead V4R as an indication of right ventricular infarction was determined by (1) autopsy findings,3,13 (2) left and right ventriculography and coronary angiography (with wall-motion abnormalities, occlusion or severe stenosis of the right coronary artery proximal to the right ventricular branch, or both used as criteria),34 (3) technetium-99m pyrophosphate imaging (15 mCi of technetium-99m coupled with 5 mg of stannous pyrophosphate; with focal uptake in projection to the right ventricle used as the criterion),9,19 (4) invasive hemodynamic measurements (right atrial pressure equal or nearly equal to the pulmonary-capillary pressure or a severely noncompliant pattern [M- or W-shaped wave form for right atrial pressure, with a Y descent deeper than the X descent] was used as the criterion)3,20.

Hemodynamic measurements and technetium-99m pyrophosphate imaging were considered only when they could be performed during the acute phase of myocardial infarction (within less than 24 hours), whereas coronary angiography and ventriculography were considered when they could be performed during hospitalization. The sensitivity (the percentage of patients with right ventricular infarctions who were identified correctly by ST-segment elevation in V4R), the specificity (the percentage of patients without right ventricular infarction who did not have ST-segment elevation in V4R), and the diagnostic accuracy of ST-segment elevation in V4R (the percentages of patients with and without right ventricular infarction who were correctly identified by the presence or absence of ST-segment elevation in V4R) were calculated for each of the four diagnostic tests. Overall diagnostic accuracy was calculated by using the results of the first test administered in each patient according to the above sequence. These tests included autopsy findings in 18 patients, angiographic and ventriculographic findings in 112, technetium-99m pyrophosphate imaging in 37, and hemodynamic findings in 20. Thirteen patients in whom none of the four tests could be performed adequately for various reasons (such as early death or technical reasons) were excluded from this analysis.

Prognostic Assessment

In-hospital and long-term outcomes were studied for all patients. The prognostic effect of ST-segment elevation in lead V4R was evaluated in relation to the clinical variables available at the time of admission, including age, sex, maximal increase in creatine kinase, initial blood pressure, history of myocardial infarction, use of thrombolytic therapy, ventricular fibrillation before hospitalization, and cardiogenic shock at the time of admission (systolic blood pressure below 90 mm Hg for more than 30 minutes, with signs of impaired peripheral circulation and, in the case of right ventricular infarction, a lack of response to volume loading, as well as a requirement for intravenous catecholamines for hemodynamic support).

There was no attempt to standardize therapy. In patients with evidence of right ventricular infarction, volume loading was the therapy of choice, and nitrates were given only in the presence of a pulmonary-capillary wedge pressure of 15 mm Hg or higher. Major in-hospital complications included ventricular fibrillation, sustained ventricular tachycardia (lasting more than 30 seconds or causing hemodynamic intolerance), cardiogenic shock, myocardial rupture, second-degree (Mobitz II) and third-degree atrioventricular block requiring temporary or permanent cardiac pacing, and reinfarction. All complications were analyzed according to whether they occurred less than 24 hours after admission or at any time during the hospitalization.

All the patients were followed for at least one year. At the end of follow-up, 141 patients were still alive. The observation period ranged from 12 to 76 months (mean [±SD], 37 ±12). Information on vital status, including causes of death and follow-up events (e.g., reinfarction, cardiac pacing, aortocoronary bypass surgery, and percutaneous transluminal angioplasty) was obtained from the patient, the general practitioner, or both by means of a standardized questionnaire.

Statistical Analysis

Means ±SD were calculated for continuous variables, and absolute and relative frequencies were measured for discrete variables35. Differences between groups were examined for statistical significance by a two-sample t-test in the case of continuous variables and by Fisher's exact test in the case of discrete variables. The independent effect of selected clinical variables on short-term mortality (during the first 24 hours and the entire hospitalization) as well as on short-term complications was assessed with multiple logistic-regression analysis and estimated as relative risks with corresponding 95 percent confidence intervals. The independent prognostic value of the clinical variables with respect to long-term survival was assessed with use of a Cox proportional-hazards model applied to the patients' survival times. From this model, survival rates were estimated after adjustment for prognostic variables. The following variables were included in the multivariate analyses: sex, age, history of myocardial infarction, increase in creatine kinase level to a value above 1000 U per liter, cardiogenic shock on admission, use of thrombolytic therapy, and the presence of ST-segment elevation of ≥ 0.1 mV in lead V4R on admission. The statistical significance of these variables in the multivariate models was evaluated by Wald's test36. All tests of significance were two-tailed, and a P value of ≤ 0.05 was considered to indicate statistical significance.

Results

In-Hospital Course of Acute Inferior Myocardial Infarction

At the time of admission, 22 of the 200 patients with acute inferior myocardial infarctions (11 percent) had cardiogenic shock. A total of 38 patients died (19 percent), and 94 patients (47 percent) had major complications during hospitalization (Table 1). Most complications occurred less than 24 hours after admission; during this period, 13 patients (7 percent) died of cardiac causes and 58 patients (29 percent) had major complications (Table 1).

Diagnostic Accuracy of ST-Segment Elevation in V4R for the Detection of Right Ventricular Infarction

Table 2. Table 2. Diagnostic Accuracy of ST-Segment Elevation in Lead V4R as an Indicator of Right Ventricular Involvement in the Study Patients with Acute Inferior Myocardial Infarctions Who Underwent Any of Four Other Diagnostic Tests.

ST-segment elevation in lead V4R on the first electrocardiogram obtained at the time of admission was observed in 107 patients (54 percent). As compared with autopsy, coronary angiography and ventriculography, technetium-99m pyrophosphate imaging, and hemodynamic measurements, ST-segment elevation in V4R predicted right ventricular infarction with a sensitivity of 76 to 92 percent, a specificity of 50 to 81 percent, and a diagnostic accuracy of 78 to 87 percent (Table 2). When one of these tests was considered in each patient according to the sequence shown in Table 2, the overall diagnostic utility of ST-segment elevation in V4R was 88 percent (for sensitivity), 78 percent (for specificity), and 83 percent (for diagnostic accuracy).

Prognostic Effect of the Right Precordial Leads

Table 3. Table 3. Clinical Characteristics, Mortality, and Complications during Hospitalization after an Acute Inferior Myocardial Infarction, According to the Presence or Absence of ST-Segment Elevation in Lead V4R. Figure 1. Figure 1. Mortality Rate and Prevalence of Major Complications during the First 24 Hours after Admission (Panel A) and the Entire Hospitalization (Panel B) among 200 Consecutive Patients with Acute Inferior Myocardial Infarctions, According to the Presence (Solid Bars) or Absence (Shaded Bars) of ST-Segment Elevation of ≥ 0.1 mV in Lead V4R.

The numbers above the bars are percentages of patients in each group. P values were determined by univariate analysis. NS denotes not significant.

There was no difference with respect to sex, age, history of myocardial infarction, use of thrombolytic therapy, and incidence of cardiogenic shock at the time of admission between the patients with and those without ST-segment elevations of ≥ 0.1 mV in V4R on the first in-hospital electrocardiogram (Table 3). However, the presence of ST-segment elevation of ≥ 0.1 mV in lead V4R identified a subgroup of patients with unfavorable clinical courses (Table 3). In the univariate analysis, ST-segment elevation in lead V4R was highly predictive of both early and overall in-hospital mortality (P<0.001) and any major complications (P<0.001), as well as of cardiogenic shock, ventricular fibrillation, third-degree atrioventricular block, and need for temporary pacing (Figure 1). Altogether, ST-segment elevation in lead V4R was associated with an in-hospital mortality of 31 percent, as compared with 6 percent in patients without such ST-segment elevation (P<0.001), and it was associated with risks of 64 and 28 percent, respectively, for major complications (P<0.001). By contrast, the presence or absence of ST-segment depression in the left precordial leads (depression of ≥ 0.1 mV in two or more of leads V1 through V5) was not associated with significant differences in mortality (22 percent vs. 14 percent, respectively) or with a higher complication rate (47 percent vs. 46 percent). When both criteria were considered together, the prognostic value was similar to that of ST-segment elevation in lead V4R alone.

Multivariate Analysis to Predict In-Hospital Course

Table 4. Table 4. Multivariate Analysis of the Prognostic Value of Clinical and Electrocardiographic Criteria for the Incidence of Death and Major Complications during Hospitalization.

A multivariate analysis of the clinical data that were available within 24 hours after admission identified ST-segment elevation in V4R at the time of admission, cardiogenic shock, age greater than 70 years, and use of thrombolytic therapy as independent prognostic features for early in-hospital mortality, overall in-hospital mortality, or both (Table 4). Only ST-segment elevation in lead V4R and cardiogenic shock were independent predictors of major complications. ST-segment elevation of ≥ 0.1 mV in lead V4R was most strongly associated with both mortality (relative risk, 7.7; 95 percent confidence interval, 2.6 to 23) and major complications (relative risk, 4.7; 95 percent confidence interval, 2.4 to 9) (Table 4).

Follow-up after Discharge from the Hospital

A total of 162 patients were discharged from the hospital. Medications prescribed at discharge did not differ significantly according to whether the patients had right ventricular infarctions or according to whether they had had in-hospital complications. During 37 ±12 months of follow-up, 21 patients died (13 percent). The mean annual mortality rate was 4.2 percent, and this rate was highest (6.8 percent) in the first year after infarction. Seventeen patients died of cardiac causes, and four patients of noncardiac causes. Twenty-one patients (13 percent) had nonfatal reinfarctions. Forty-six patients (28 percent) required aortocoronary bypass surgery, percutaneous transluminal angioplasty, or both. Seven patients required permanent cardiac pacing 3.2 ±3 months after discharge from the hospital.

Figure 2. Figure 2. Estimated Probabilities of Survival for All 200 Patients with Acute Inferior Myocardial Infarctions over a Six-Year Follow-up Period.

The mean follow-up was 3.1 ±1 years. Survival rates are stratified according to the presence or absence of right ventricular infarction as predicted by ST-segment elevation of ≥ 0.1 mV in lead V4R at the time of admission, after adjustment for all other important prognostic variables. The numbers at the bottom of the graph are the numbers of patients in each group who were at risk at each time point.

Cox regression analysis showed that only age and a history of myocardial reinfarction were associated with increased mortality after discharge from the hospital. In addition, ST-segment elevation in lead V4R during the acute phase of inferior myocardial infarction was predictive of a later requirement for permanent pacing (P = 0.048). Cox regression analysis was also used to estimate the overall survival distribution of patients with and without right ventricular infarction after adjustment for the other important prognostic variables (Figure 2).

Discussion

Our consecutive series of patients with acute inferior myocardial infarctions had an in-hospital mortality of 19 percent and a 47 percent incidence of major complications (e.g., cardiogenic shock, ventricular fibrillation, and high-degree atrioventricular conduction block). ST-segment elevation of ≥ 0.1 mV in V4R, shown to be a reliable diagnostic criterion for right ventricular infarction, was present in half the patients with inferior myocardial infarctions and was the most accurate independent prognostic indicator of the in-hospital course. The presence of right ventricular infarction increased in-hospital mortality from 5 to 31 percent (P<0.001), and the rate of major complications rose from 28 to 64 percent (P<0.001).

Prognosis of Acute Inferior Myocardial Infarction

Inferior myocardial infarction is usually considered to have a better prognosis in both the short and the long term than anterior myocardial infarction10,11. Recent studies of inferior myocardial infarction, however, evaluated a selected population of patients suitable for thrombolytic therapy, including 9 to 38 percent of the patients screened37,38. Pooled data on the controls in nine of these studies indicate an in-hospital mortality of 8.6 percent and a 50 percent risk of in-hospital complications37. Both mortality rates and in-hospital complication rates increased markedly in the 60 to 80 percent of patients not suitable for thrombolytic therapy37-40. In our series of consecutive patients, two thirds of those with inferior myocardial infarctions had contraindications to thrombolytic therapy, and these patients accounted for a substantial proportion of the high overall in-hospital mortality. Among the 36 percent who were suitable for thrombolytic therapy, in-hospital mortality was 7 percent, but this figure increased by more than three times among the patients who were not candidates for thrombolytic therapy.

Risk stratification of patients with acute inferior myocardial infarctions has been assessed by others4,37,41. Because therapeutic interventions are most effective when applied early, readily assessable clinical features of prognostic importance are needed at the time of admission to the hospital. In this study, multivariate analysis revealed the absence of right ventricular infarction as diagnosed by ST-segment elevation in lead V4R, age of less than 70 years, the absence of cardiogenic shock on admission, and the use of thrombolytic therapy to be predictive of lower in-hospital mortality. Only the absence of right ventricular infarction and the absence of cardiogenic shock on admission predicted, in addition, a lower rate of major in-hospital complications.

The electrocardiogram, which is readily available, simple, and objective, has been used to relate infarct size to prognosis. Bates et al.42 found that precordial ST-segment depression predicted a poor prognosis in inferior myocardial infarction, even when reperfusion therapy was used. Other studies have also confirmed an unfavorable clinical course when electrocardiographic criteria suggested a larger infarction and, as a consequence, more extensive left ventricular dysfunction9,41,43-45. The role of right ventricular infarction, however, has been studied less extensively.

Diagnostic Accuracy of ST Elevation in V4R for Right Ventricular Infarction

Right ventricular infarction complicates about 50 percent of acute inferior myocardial infarctions2-4,15,26. ST-segment elevations and Q waves in the right precordial leads (V3R through V6R) have previously been shown to have a diagnostic accuracy for right ventricular infarction greater than 80 percent26 or greater than 90 percent22,30. In the present study, four diagnostic procedures,3 including autopsy,13 coronary angiography and ventriculography,34 technetium-99m pyrophosphate imaging,18,19 and hemodynamic measurements,20 were considered to assess the accuracy of ST-segment elevation in lead V4R in the diagnosis of right ventricular infarction. Diagnostic accuracy was found to be well above 85 percent for ST-segment elevation in lead V4R as assessed by the first three tests, whereas previously recommended criteria for hemodynamic measurements resulted in a diagnostic accuracy of only 78 percent. The overall diagnostic accuracy was calculated by using the result of one test per patient in the sequence given above. Thus, ST-segment elevation in lead V4R had an overall sensitivity of 88 percent, a specificity of 78 percent, and a diagnostic accuracy of 83 percent for the diagnosis of right ventricular involvement during acute inferior myocardial infarction.

Prognostic Effect of Right Ventricular Involvement during Acute Inferior Myocardial Infarction

The prognostic effect of electrocardiographic criteria for right ventricular infarction is uncertain. The studies by Andersen et al.27 and Rodrigues et al.14 described fewer than 50 patients with right ventricular infarctions, but they strongly suggested that right precordial ST-segment elevation is a marker for the prognosis.

The present study confirms these observations in a larger number of patients. ST-segment elevation in V4R was shown to be a strong independent prognostic marker and superior to the other clinical variables that were assessed at the time of admission to the hospital. Patients with ST-segment elevation in V4R had a 12 percent risk of death and a 43 percent risk of major complications during the first 24 hours in the hospital. In the absence of ST-segment elevation, no patients died during this period, and the complication rate was more than two times lower. As compared with all clinical variables available at the time of admission, right ventricular infarction was associated with a relative risk of in-hospital mortality of 7.7 (95 percent confidence interval, 2.6 to 23) and a risk of major in-hospital complications of 4.7 (95 percent confidence interval, 2.4 to 9). Ultimately, 95 percent of patients without evidence of right ventricular infarction at the time of admission were discharged from the hospital, as compared with only 69 percent of those in whom right ventricular infarction complicated the acute inferior myocardial infarction.

The prognostic effect of right ventricular infarction was independent of and superior to the precordial ST-segment depression frequently used to indicate a larger area of left ventricular infarction42. When patients with and those without right ventricular infarctions were compared, the left ventricular ejection fractions did not differ between the two groups. Therefore, during an acute inferior infarction, not only the size but also the location of the infarct zone (left vs. right ventricle) is of major prognostic interest and should be considered a guide to aggressive treatment strategies.

Prognostic Importance of Right Ventricular Involvement for Long-Term Survival

The long-term prognosis of patients with right ventricular involvement during inferior myocardial infarctions is unknown4. In patients with inferior myocardial infarctions, whether complicated by right ventricular involvement or not, annual mortality was found to be 4.2 percent overall and 6.8 percent during the first year. In the only study providing similar data on a small group of patients with right ventricular infarctions, annual mortality was 4 percent during a 1.8-year follow-up27. Except for advanced age and a history of myocardial reinfarction, none of the clinical or electrocardiographic criteria evaluated by Cox regression analysis were of prognostic importance for the clinical course after the patient survived the in-hospital phase. Right ventricular infarction, however, was predictive of a later requirement for permanent pacing.

Limitations of the Electrocardiogram in the Diagnosis of Right Ventricular Infarction

The use of ST-segment elevation in lead V4R for the diagnosis of right ventricular infarction is known to lose specificity in the presence of any heart disease that may induce ST-segment elevation in lead V1, such as pericardial disease, acute pulmonary embolism, left anterior fascicular block, and acute anterior myocardial infarction (present in 10 percent of patients with right ventricular involvement8). The diagnostic accuracy of right precordial ST-segment elevation is considered to be greatest during the first 10 hours after an acute infarction, which underscores the need for an electrocardiographic assessment as soon as possible after admission to the hospital26,46.

Clinical Implications

Involvement of the right ventricle in acute inferior myocardial infarction is common, and the early recognition of this involvement has important prognostic implications. Right ventricular infarction can be diagnosed accurately on the basis of an ST-segment elevation of ≥ 0.1 mV in the right precordial leads (e.g., lead V4R) soon after the onset of infarction, and this elevation indicates a significantly increased risk of major complications and in-hospital death.

Funding and Disclosures

We are indebted to Drs. Frank Marcus, L. Frye, and William Stevenson for their critical comments on the study protocol and data interpretation before the submission of the manuscript for review.

Author Affiliations

From the Abteilung fur Kardiologie, Innere Medizin III (M.Z., W.K., E.K., M.S., A.G., H.J.), and the Abteilung fur Medizinische Biometrie und Informatik (M.O.), Universitatsklinik Freiburg, Freiburg, Germany.

Address reprint requests to Dr. Zehender at Innere Medizin III, Universitatsklinik Freiburg, Hugstetterstr. 55, 78 Freiburg, Germany.

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Citing Articles (476)

    Letters

    Figures/Media

    1. Table 1. Clinical Characteristics and In-Hospital Outcomes in 200 Consecutive Patients with Acute Inferior Myocardial Infarctions.
      Table 1. Clinical Characteristics and In-Hospital Outcomes in 200 Consecutive Patients with Acute Inferior Myocardial Infarctions.
    2. Table 2. Diagnostic Accuracy of ST-Segment Elevation in Lead V4R as an Indicator of Right Ventricular Involvement in the Study Patients with Acute Inferior Myocardial Infarctions Who Underwent Any of Four Other Diagnostic Tests.
      Table 2. Diagnostic Accuracy of ST-Segment Elevation in Lead V4R as an Indicator of Right Ventricular Involvement in the Study Patients with Acute Inferior Myocardial Infarctions Who Underwent Any of Four Other Diagnostic Tests.
    3. Table 3. Clinical Characteristics, Mortality, and Complications during Hospitalization after an Acute Inferior Myocardial Infarction, According to the Presence or Absence of ST-Segment Elevation in Lead V4R.
      Table 3. Clinical Characteristics, Mortality, and Complications during Hospitalization after an Acute Inferior Myocardial Infarction, According to the Presence or Absence of ST-Segment Elevation in Lead V4R.
    4. Figure 1. Mortality Rate and Prevalence of Major Complications during the First 24 Hours after Admission (Panel A) and the Entire Hospitalization (Panel B) among 200 Consecutive Patients with Acute Inferior Myocardial Infarctions, According to the Presence (Solid Bars) or Absence (Shaded Bars) of ST-Segment Elevation of ≥ 0.1 mV in Lead V4R.
      Figure 1. Mortality Rate and Prevalence of Major Complications during the First 24 Hours after Admission (Panel A) and the Entire Hospitalization (Panel B) among 200 Consecutive Patients with Acute Inferior Myocardial Infarctions, According to the Presence (Solid Bars) or Absence (Shaded Bars) of ST-Segment Elevation of ≥ 0.1 mV in Lead V4R.

      The numbers above the bars are percentages of patients in each group. P values were determined by univariate analysis. NS denotes not significant.

    5. Table 4. Multivariate Analysis of the Prognostic Value of Clinical and Electrocardiographic Criteria for the Incidence of Death and Major Complications during Hospitalization.
      Table 4. Multivariate Analysis of the Prognostic Value of Clinical and Electrocardiographic Criteria for the Incidence of Death and Major Complications during Hospitalization.
    6. Figure 2. Estimated Probabilities of Survival for All 200 Patients with Acute Inferior Myocardial Infarctions over a Six-Year Follow-up Period.
      Figure 2. Estimated Probabilities of Survival for All 200 Patients with Acute Inferior Myocardial Infarctions over a Six-Year Follow-up Period.

      The mean follow-up was 3.1 ±1 years. Survival rates are stratified according to the presence or absence of right ventricular infarction as predicted by ST-segment elevation of ≥ 0.1 mV in lead V4R at the time of admission, after adjustment for all other important prognostic variables. The numbers at the bottom of the graph are the numbers of patients in each group who were at risk at each time point.

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