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.

Objective-To determine the ability of conventional and Doppler echocardiography to distinguish between minor, acute massive, and subacute massive pulmonary embolism in patients with confirmed pulmonary embolism. Design-Prospective study of a consecutive series of 47 patients with confirmed pulmonary embolism. Setting-Department of internal medicine, university clinic. Patients-l1 patients (23%) had minor, 23 patients (49%/6) had acute massive, and 13 patients (28%) had subacute massive pulmonary embolism. Results-Dilatation of the right ventricular cavity (33 (92%)) and asynergy of the right ventricular free wall (29 (81%)) were seen only in patients with acute and subacute massive pulmonary embolism (n = 36). 23 (64%) with pulmonary hypertension had tricuspid regurgitation. The velocity of the tricuspid regurgitant jet correlated with the pulmonary arterial pressure (r = 0-88, SEE = 11*6 mm Hg) and was significantly lower in patients with acute massive pulmonary embolism (3.0 (0.4) mI/s, n = 12) than in patients with subacute massive pulmonary embolism (4.2 (0-6) mIs; n = 11) (p < 0.001). (18) years) pulmonary embolism was confirmed by pulmonary angiography (n = 44(94%) or by a typical ventilation-perfusion lung scan and precapillary pulmonary hypertension (n = 3(6%).Those with normal pulmonary arterial pressure were diagnosed as having minor pulmonary embolism. Patients with pulmonary hypertension (defined as an increase in mean pulmonary arterial pressure of >20 mm Hg at rest) were considered to have acute massive pulmonary embolism. Subacute massive pulmonary embolism-was defined as a mean pulmonary arterial pressure of >40 mm Hg or systolic pulmonary arterial pressure of >70 mm Hg or both.' 2 Patients in whom the first clinical symptoms of suspected pulmonary embolism started >8 weeks before presentation were excluded.

During acute inferior myocardial infarction, the right precordial electrocardiogram is a simple but promising variable to identify a subgroup of patients with an unfavorable course who will benefit most from thrombolytic therapy.

We report on a case of fatal pulmonary embolism in a 68-yearold patient receiving antipsychotic treatment with haloperidol and olanzapine for acute exacerbation of her schizophrenia and having been physically restrained for 27.5 h. Pulmonary embolism was verifi ed by autopsy. With reference to a review of the recent literature we briefl y discuss current recommendations for prophylaxis of venous thromboembolism (VTE) in clinical psychiatry, which is a rare but highly relevant complication of antipsychotic treatment.

Objective-To determine the diagnostic and prognostic impact of abnormal Q waves in comparison to or in combination with ST In the acute phase of inferior infarction ST segment elevation > 0 I mV in any of the right precordial leads V4-6R was the most reliable criterion for right ventricular infarction (sensitivity, 89%; specificity, 83%). Abnormal Q waves in the right precordial leads, the most specific criterion (91%) for right ventricular infarction, were superior to ST segment elevation in patients admitted >12 hours after the onset of symptoms. Both ST segment elevation in leads V4-6R (increase in in hospital mortality, 6-2-times; P < 0*001; major complications, 2-3-times; P < 0.01) and abnormal Q waves (2.3-times, P < 0*05; 1-8-times, P < 0.05) on admission were highly predictive of a worse outcome during the in hospital period. In the presence of inferior myocardial infarction previously proposed combined electrocardiographic criteria were not better diagnostically or prognostically than ST segment abnormalities and abnormal Q waves alone. Conclusions-During the first 24 hours of inferior myocardial infarction ST segment elevation and abnormal Q waves derived from the right precordial leads are complementary rather than competitive criteria for reliably diagnosing right ventricular infarction, both indicating a worse in hospital course for the patient. In this they are better than any other previously proposed combined electrocardiographic criteria in diagnosing right ventricular infarction. Right precordial leads should be routinely monitored in acute inferior myocardial infarction. (Br Heart J 1994;72:119-124)