1. This almost always occurs in the presence of a concurrent inferior MI. 2. Clinical findings may include the triad of hypotension, JVD, and clear lungs. 3. ECG clues: in the presence of inferior lead ischemia or injury pattern, look for: a. Combination of ST depression in lead V2 + ST elevation in lead V1; OR b. Combination of ST depression in lead V2 + isoelectric ST segments in leads V1 and V3; OR c. ST elevation in lead III markedly greater than the ST elevation in lead II; OR d. ST elevation in right-sided leads (requires you to obtain right-sided leads)
Why is this diagnosis important? 1. It suggests a larger infarction and worse prognosis, so BE AGGRESSIVE in management. 2. Be very cautious with preload-reducing medications (e.g. nitrates) in the acute management of these patients, as they may induce significant reductions in blood pressure and extension of the infarction. Be aggressive with IVF, while maintaining close attention to the lung sounds.
