A 78 year old patient was referred for a cardiology opinion following the incidental discovery of Q waves in leads III and aVF on a 12 lead ECG (upper panel). There was also ST segment depression in leads I, aVL, V5, and V6 and electrical evidence of left ventricular hypertrophy. There was no definite history suggestive of myocardial ischaemia and cardiovascular risk factors included previous smoking and hypertension. On examination the patient’s blood pressure was 182/88 mm Hg.

Transthoracic echocardiography showed preserved left ventricular (LV) and right ventricular (RV) systolic function with normal dimensions. In particular there was no inferior wall motion abnormality.

In order to resolve this conflict in information cardiac magnetic resonance imaging (CMR) was undertaken (Siemens Sonata 1.5T system with a phased array chest coil). LV function and dimensions were normal and no wall motion abnormality was present. However, the RV was hypokinetic with an ejection fraction of 43%. Delayed hyperenhancement imaging for myocardial infarction was performed 10 minutes post-intravenous contrast injection (0.1 mmol/kg gadolinium DTPA). This revealed an extensive transmural RV myocardial infarction as indicated by the arrows (lower panel).

CMR confirmed the diagnosis of isolated RV infarction and demonstrates that this may lead to chronic RV systolic impairment. Symptomatic isolated RV infarction is uncommon and the prevalence of silent RV ischaemia is unknown. Confirmation of the diagnosis of myocardial infarction is always of clinical importance and secondary prevention has now been advised with aspirin, a β blocker, an angiotensin converting enzyme inhibitor, and a statin.