What lies beneath: Posterior ST elevation myocardial infarction with underlying right ventricular-paced rhythm

A 66-year-old man with a history of coronary artery disease, stage V chronic kidney disease, peripheral arterial disease and a dual-chamber pacemaker experienced persistent chest and shoulder discomfort following his daily hemodialysis treatment. Treatment with clopidogrel had been discontinued three days previously due to impending vascular surgery. Electrocardiography revealed a right ventricular-paced rhythm with ST abnormalities indicative of posterior ST elevation myocardial infarction. The patient underwent urgent cardiac catheterization and required percutaneous coronary intervention for an acutely occluded coronary artery. The present case report emphasizes the importance of careful and timely review of the electrocardiogram of any patient with a ventricular-paced rhythm who experiences signs and symptoms consistent with acute coronary syndrome. Certain characteristic electrocardiographic abnormalities have been demonstrated to predict acute myocardial infarction in such patients.