Acute myocardial infarction (MI) is a common presentation of acute coronary syndrome and is frequently related to right coronary artery (RCA) occlusion. In a proportion of patients, particularly those with a culprit lesion involving the proximal RCA, myocardial ischemia extends beyond the inferior wall of the left ventricle to involve the right ventricle (RV). The anatomical relationship between the RCA and the RV explains this association, as the proximal RCA gives rise to right ventricular marginal branches that supply substantial portions of the RV myocardium. Consequently, the location of the RCA culprit lesion may have important implications for the extent of myocardial injury and the development of RV dysfunction. ⁵

Right ventricular involvement in acute inferior MI is clinically important because the RV plays a central role in maintaining pulmonary blood flow, left ventricular preload, and systemic cardiac output. Acute RV dysfunction may result in reduced forward flow through the pulmonary circulation and consequently decreased left ventricular filling. Clinically, this may manifest as hypotension, elevated jugular venous pressure, systemic venous congestion, and, in severe cases, cardiogenic shock. Recognition of RV involvement is therefore important during the initial evaluation and management of patients with inferior MI, particularly in the setting of hemodynamic instability. ¹˒⁵

Electrocardiography remains an important component of the early assessment of patients with suspected RV involvement. The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients with Acute Coronary Syndromes recommends obtaining right-sided ECG leads in patients with concern for inferior STEMI to evaluate for right ventricular involvement. ¹ Right-sided leads, particularly V4R, may provide useful evidence of RV ischemia or infarction. However, the electrocardiographic manifestations of RV involvement may vary according to the timing of recording, the extent of myocardial ischemia, spontaneous or therapeutic reperfusion, and the anatomical location of the RCA lesion. Thus, although right-sided ECG assessment is clinically useful, it may not completely characterize the degree or regional distribution of RV myocardial dysfunction. ¹

Echocardiography provides an important complementary method for assessing RV function in patients with acute MI. Conventional echocardiographic parameters such as tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV FAC), and tricuspid annular peak systolic velocity (S′) are widely used for evaluation of RV systolic function. These parameters are simple and clinically applicable; however, each has inherent limitations. TAPSE and S′ primarily reflect longitudinal motion of the lateral tricuspid annulus and may not represent global or regional RV myocardial performance. RV FAC provides information about changes in RV area but can be influenced by image quality and endocardial delineation. Furthermore, conventional measurements may be affected by loading conditions and may not detect subtle or regional myocardial dysfunction at an early stage. ⁹

The complex geometry of the RV further contributes to the limitations of conventional echocardiographic assessment. Unlike the relatively symmetrical left ventricle, the RV has a crescent-shaped configuration and exhibits complex longitudinal and radial contraction. A substantial component of normal RV systolic function is related to longitudinal shortening of the RV free wall. Assessment of myocardial deformation therefore provides an opportunity to evaluate RV performance from a different physiological perspective. Two-dimensional speckle-tracking echocardiography (2D-STE) enables quantification of myocardial deformation by tracking acoustic markers, or speckles, within the myocardium throughout the cardiac cycle. ⁷˒⁸

Right ventricular free-wall longitudinal strain (RV-FWLS) is a deformation-based parameter that evaluates longitudinal shortening of the basal, mid, and apical segments of the RV free wall. Because strain reflects myocardial deformation rather than simple annular displacement, RV-FWLS may provide additional information regarding regional myocardial injury and systolic dysfunction. A less-negative strain value indicates reduced myocardial shortening and impaired deformation. This characteristic makes RV-FWLS potentially useful for identifying RV myocardial involvement even when conventional measures of RV systolic function are relatively preserved. ⁷˒⁸

Several studies have investigated the relationship between RV-FWLS and the anatomical location of RCA lesions in patients with acute inferior MI. Gecmen et al. evaluated 77 patients with inferior MI and compared patients with RCA occlusion proximal to the RV branch with those having more distal occlusion. RV-FWLS was independently associated with proximal RCA occlusion, and receiver operating characteristic analysis demonstrated an area under the curve (AUC) of 0.81. An RV-FWLS value greater than −14.75% identified proximal RCA occlusion with a sensitivity of 83% and specificity of 61%. These findings suggested that impairment of RV free-wall deformation may reflect the anatomical extent of RCA-related myocardial injury. ²

Similarly, Roshdy et al. studied patients with acute inferior MI and evaluated several conventional and speckle-tracking echocardiographic parameters of RV function. Patients with RV involvement demonstrated greater impairment of RV deformation together with abnormalities in conventional measures of RV function. Importantly, an RV average free-wall longitudinal strain threshold of ≥−19.7% was associated with proximal RCA culprit lesions, with a reported sensitivity of 91.7% and specificity of 70.5%. RV-FWLS also remained an independent predictor of proximal RCA culprit disease in multivariable analysis. ³

Further evidence was provided by Ahmed et al., who evaluated patients with recent inferior wall MI, including patients undergoing primary percutaneous coronary intervention. Among patients with an RCA culprit lesion, those with a lesion proximal to or involving the RV branch had significantly lower RV-FWLS than patients with a distal RCA lesion. RV-FWLS demonstrated the strongest discriminatory capability among the evaluated RV parameters, with an AUC of 0.70. These findings support the concept that deformation imaging may provide additional information regarding RV involvement beyond conventional echocardiographic measurements. ⁴

Despite these observations, important uncertainties remain. Published studies have used different patient populations, timing of echocardiographic assessment, echocardiographic software platforms, definitions of proximal RCA disease, and RV-FWLS thresholds. Consequently, reported strain cut-off values have varied considerably between studies. In addition, the incremental diagnostic value of RV-FWLS compared with established parameters such as TAPSE, RV FAC, and tricuspid annular S′ has not been uniformly demonstrated. Standardization of deformation imaging acquisition and interpretation remains important when comparing strain measurements between different studies and echocardiographic platforms. ⁷˒⁸

From a pathophysiological perspective, the relationship between proximal RCA disease and RV-FWLS is clinically plausible. A proximal RCA lesion occurring before the origin of major RV branches can compromise blood supply to the RV free wall, resulting in myocardial ischemia and reduced longitudinal deformation. In contrast, a distal RCA lesion occurring beyond the major RV branches may cause inferior LV ischemia while relatively preserving RV myocardial perfusion. The association between proximal RCA occlusion and impaired RV longitudinal function has also been demonstrated in previous echocardiographic studies. ²˒⁵ Therefore, a quantitative assessment of RV free-wall deformation may provide indirect information regarding the anatomical location of the culprit RCA lesion.

The identification of proximal RCA involvement has potential clinical relevance because patients with significant RV involvement may require closer hemodynamic assessment and appropriate modification of acute management. RV-FWLS should not be considered a replacement for clinical assessment, ECG, coronary angiography, or conventional echocardiography; rather, it may serve as a complementary quantitative parameter that provides additional information about RV myocardial involvement. ¹˒⁷

Therefore, the present study was undertaken to evaluate the diagnostic utility of right ventricular free-wall longitudinal strain measured by two-dimensional speckle-tracking echocardiography in patients with acute inferior myocardial infarction. The primary objective was to determine the ability of RV-FWLS to identify proximal RCA involvement using coronary angiographic findings as the reference standard. The diagnostic performance of RV-FWLS was also compared with conventional measures of RV systolic function, including TAPSE, RV FAC, and tricuspid annular S′ velocity. By examining both deformation-based and conventional echocardiographic parameters, this study aimed to determine whether RV-FWLS provides additional information for identifying patients with proximal RCA disease and potential RV involvement during acute inferior MI.

2. Aim and Objectives

Primary Objective

To determine the diagnostic utility of right ventricular free-wall longitudinal strain measured by two-dimensional speckle-tracking echocardiography for identifying proximal right coronary artery (RCA) lesions in patients with acute inferior myocardial infarction. ²⁻⁴

Secondary Objectives

1. To assess right ventricular systolic function using TAPSE, RV FAC, and tricuspid annular S′ velocity. ⁹
2. To compare RV-FWLS between patients with proximal and distal RCA involvement. ²⁻⁵
3. To compare the diagnostic performance of RV-FWLS with conventional RV functional parameters, including TAPSE, RV FAC, and tricuspid annular S′ velocity. ⁷⁻⁹

.1 Study design and setting

This was a cross-sectional observational study conducted in the Department of Cardiology, BLDE (Deemed to be University), Shri B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. The study period was July 2024 to January 2026. A total of 80 patients were included.

3.2 Study population

3.3 Inclusion Criteria

Patients will be eligible for inclusion in the study if they fulfill all of the following criteria:

1. Age ≥18 years.
2. Acute inferior myocardial infarction, defined by compatible clinical symptoms such as acute-onset chest pain, chest discomfort, dyspnea, diaphoresis, or equivalent ischemic symptoms, together with electrocardiographic evidence of acute myocardial infarction.¹⁰
3. Electrocardiographic evidence of inferior STEMI, characterized by ST-segment elevation ≥1 mm in at least two contiguous inferior leads (II, III, and aVF).¹⁰
4. Patients with associated electrocardiographic evidence suggestive of right ventricular involvement, including:

• ST-segment elevation in V4R ≥1 mm, when right-sided ECG leads are recorded; and/or
• ST-segment elevation in V1 with reciprocal ST-segment depression in V2, when present.¹˒¹⁰

5. Patients presenting within the acute phase of myocardial infarction and undergoing evaluation and management according to the institutional acute coronary syndrome protocol.
6. Coronary angiography demonstrating RCA as the culprit coronary artery, allowing classification into:²⁻⁵

• Proximal RCA lesion: culprit lesion located proximal to or involving the origin of the major right ventricular branches.
• Distal RCA lesion: culprit lesion located distal to the major right ventricular branches.

7. Adequate transthoracic echocardiographic image quality permitting reliable assessment of RV systolic function and measurement of RV-FWLS by two-dimensional speckle-tracking echocardiography.⁷˒⁸
8. Availability of adequate echocardiographic measurements of the predefined conventional RV functional parameters, including TAPSE, RV FAC, and tricuspid annular S′ velocity, for comparison with RV-FWLS.⁴˒⁹
9. Patients who provide written informed consent for participation in the study.

3.4 Exclusion Criteria

Patients will be excluded from the study if they have any of the following:

1. **Cardiogenic shock or hemodynamic instability. **¹⁰
2. Previous myocardial infarction or previous coronary intervention, including PCI or CABG.
3. Significant (>50%) lesion in the LAD or LCX arteries, which may contribute to myocardial ischemia or ventricular dysfunction independent of the RCA culprit lesion.
4. Atrial fibrillation, which may affect reliable assessment of cardiac cycle-dependent echocardiographic parameters and RV strain.
5. Atrioventricular block or significant ventricular arrhythmias, which may interfere with hemodynamic assessment and reliable acquisition of echocardiographic measurements.
6. Active infection or systemic inflammatory illness, which may influence cardiac function and clinical hemodynamic status.
7. Severe pulmonary disease, particularly conditions associated with pulmonary hypertension or secondary RV dysfunction. ⁹
8. Cor pulmonale or pre-existing significant right ventricular dysfunction, which may independently alter RV-FWLS and conventional RV functional parameters. ⁹
9. Poor echocardiographic image quality that does not permit reliable assessment of RV systolic function or adequate tracking for RV-FWLS measurement. ⁷˒⁸

3.5 Echocardiographic assessment

RV systolic function was assessed using TAPSE, RV FAC and tricuspid annular S′ velocity. RV-FWLS was measured from an RV-focused apical four-chamber view by tracing the RV endocardial border and allowing automated tracking of the basal, mid and apical RV free-wall segments. The average peak longitudinal strain of the three free-wall segments was recorded, excluding the interventricular septum.

• RV-focused apical 4-chamber view
  ⬇
  Clearly visualize RV free wall
                        ⬇
  Trace RV endocardial border
                        ⬇
  Automatic tracking of basal, mid, and apical free wall segments
                        ⬇
  Exclude interventricular septum
                        ⬇
  Average peak longitudinal strain of 3 free wall segments
                        ⬇
  RV Free Wall Longitudinal Strain (%)
• Interpretation
• Normal: ≤ −25% ± 5%
• Less negative values → RV dysfunction / proximal RCA lesion

3.6 Coronary angiography

Coronary angiography was performed as part of the clinical evaluation and was used to classify RCA involvement as proximal or distal according to the location of the lesion in relation to the RV branch territory, as defined by the study protocol.

3.7 Statistical analysis

Data were analyzed using SPSS version 23.0. Continuous variables were summarized as mean ± standard deviation and categorical variables as frequency and percentage. Independent-samples t-test was used for continuous variables and chi-square test for categorical variables. ROC analysis was used to determine the optimal RV-FWLS threshold and calculate AUC, sensitivity and specificity. The supplied study presentation specified p<0.01 as the threshold for statistical significance; therefore, p-values between 0.01 and 0.05 are reported as nominal findings and are not classified as statistically significant under the prespecified threshold.

.1 Distribution of RCA lesions

Of the 80 patients, 45 (56.3%) had proximal RCA lesions and 35 (43.7%) had distal RCA lesions.

4.2 Demographic characteristics

4.4 Risk Factors Distribution

.5 Biochemical findings

.6. Conventional Echocardiographic Parameters

.7 Diagnostic performance

 Area under the ROC curve for the echocardiographic parameters evaluated for proximal RCA lesion detection.

The principal finding of the present study was that right ventricular free-wall longitudinal strain (RV-FWLS) was significantly impaired in patients with proximal right coronary artery (RCA) involvement compared with those who had distal RCA lesions. Mean RV-FWLS was −12.8% in the proximal RCA group compared with −17.6% in the distal RCA group (p=0.001). The less-negative strain values observed in patients with proximal RCA involvement indicate greater impairment of longitudinal deformation of the RV free wall. This finding is physiologically plausible because the proximal RCA gives rise to important right ventricular branches that supply the RV free wall. Occlusion proximal to these branches can therefore produce more extensive RV myocardial ischemia and impairment of longitudinal myocardial shortening. In contrast, distal RCA lesions may preserve perfusion to much of the RV free wall while producing predominantly inferior left ventricular myocardial injury.⁵

The diagnostic performance of RV-FWLS in the present study was also notable. An area under the receiver operating characteristic curve (AUC) of 0.86 was observed at an RV-FWLS threshold of ≥−16.0%, with a sensitivity of 81.6% and specificity of 77.2% for identifying proximal RCA involvement. The relatively high AUC indicates good discriminatory ability of RV-FWLS in distinguishing proximal from distal RCA lesions in this study population. Importantly, the diagnostic performance of RV-FWLS was superior to that of tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV FAC), and tricuspid annular S′ velocity in the present cohort. These findings suggest that deformation-based assessment may provide additional information regarding the regional effects of RCA occlusion that may not be completely captured by conventional measures of RV systolic function.⁷˒⁸

The association between proximal RCA disease and impaired RV deformation is supported by the anatomical and physiological characteristics of the RV. The RV free wall depends substantially on longitudinal shortening for systolic contraction. Ischemia involving the RV free wall can therefore result in an early reduction in longitudinal myocardial deformation. Because RV-FWLS measures myocardial deformation directly, it may detect regional ischemic abnormalities before they result in a marked reduction in global RV systolic performance. This may explain why RV-FWLS demonstrated better discrimination than selected conventional parameters in the present study.⁷˒⁸

Our findings are consistent with previous investigations examining the role of RV strain in patients with inferior myocardial infarction. Gecmen et al. evaluated 77 patients with inferior MI and reported that RV free-wall strain independently predicted proximal RCA occlusion. In their study, an RV free-wall strain threshold greater than −14.75% demonstrated 83% sensitivity and 61% specificity, with an AUC of 0.81.² The AUC observed in our study was 0.86, indicating comparable discriminatory performance in our study population. However, direct comparison of diagnostic accuracy between studies should be undertaken cautiously because differences in patient selection, strain acquisition techniques, timing of echocardiographic examination, and definitions of proximal RCA disease can influence the results.

Similarly, Roshdy et al. reported that an RV average free-wall longitudinal strain threshold of ≥−19.7% identified significant proximal RCA culprit lesions, with a sensitivity of 91.7% and specificity of 70.5%.³ Although the threshold identified in our study was different (≥−16.0%), the direction of association was similar: less-negative RV-FWLS values were associated with proximal RCA involvement. This consistency across studies supports the physiological concept that proximal RCA occlusion, through involvement of RV branches, produces measurable impairment in RV myocardial deformation.²˒³

A further study involving patients with RCA culprit lesions also demonstrated that RV-FWLS was among the echocardiographic parameters most strongly associated with RV involvement.⁴ Taken together, these observations suggest that RV deformation imaging may have a role in anatomical characterization of RCA-related myocardial injury in addition to its established role in assessing RV function. The present study adds to this evidence by demonstrating a significant difference in RV-FWLS between proximal and distal RCA disease and by evaluating its diagnostic performance against conventional echocardiographic parameters.

The differences in RV-FWLS thresholds between published studies deserve consideration. Strain measurements are not completely interchangeable across different echocardiographic systems and software platforms. Vendor-specific algorithms, tracking quality, frame rate, image acquisition, definition of the RV free-wall segments, and methods used to calculate average strain may influence the measured values. In addition, RV strain can be affected by loading conditions, heart rate, timing of imaging after coronary reperfusion, infarct size, and the extent of RV myocardial involvement. Differences in patient characteristics and the angiographic definition of proximal RCA disease may also contribute to variability. Standardization of deformation imaging acquisition and interpretation remains important when comparing strain values between studies and institutions.⁸ Therefore, the threshold of ≥−16.0% identified in the present study should be regarded as a cohort-specific diagnostic threshold rather than a universal cutoff. External validation in larger and independent populations will be required before this value can be applied broadly in clinical practice.

Conventional echocardiographic parameters remained clinically relevant in the present study, although they demonstrated lower discriminatory performance than RV-FWLS. TAPSE primarily measures longitudinal displacement of the lateral tricuspid annulus and therefore represents a relatively limited component of total RV contraction. RV FAC provides a two-dimensional estimate of RV systolic function but may be influenced by RV geometry, image quality, and accurate delineation of the endocardial border. Tissue-Doppler S′ provides a useful measure of longitudinal systolic velocity but is dependent on the angle of insonation and primarily reflects motion at the sampled annular region.⁹ In comparison, RV-FWLS provides a segmental assessment of myocardial deformation involving the RV free wall and may therefore be more sensitive to regional ischemic abnormalities.⁷˒⁸

The clinical relevance of these findings is particularly important in acute inferior MI, where identification of RV involvement can influence hemodynamic assessment and management. Patients with significant RV dysfunction may be sensitive to changes in preload and may develop hypotension or systemic venous congestion. The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline recommends right-sided ECG assessment when RV involvement is suspected in patients with inferior STEMI.¹ Although RV-FWLS cannot replace clinical assessment, right-sided ECG leads, conventional echocardiography, or coronary angiography, it may provide an additional quantitative marker of RV myocardial involvement. In patients in whom the electrocardiographic findings are equivocal or conventional RV parameters are not markedly abnormal, RV-FWLS may potentially provide complementary information regarding the likelihood of proximal RCA disease.¹˒⁷

The present findings should nevertheless be interpreted primarily as evidence of a diagnostic association rather than proof of prognostic significance. The study was cross-sectional and did not include longitudinal assessment of clinical outcomes such as mortality, cardiogenic shock, heart failure, or major adverse cardiovascular events. Therefore, although impaired RV-FWLS was associated with proximal RCA involvement, it cannot be concluded from the present study that RV-FWLS independently predicts adverse clinical outcomes. In addition, the study included only patients with adequate echocardiographic image quality, which may introduce selection bias and limit generalizability to patients with technically difficult examinations. Other potential limitations include the influence of loading conditions and the timing of echocardiographic assessment during the acute phase of MI. Differences in strain acquisition and analysis between echocardiographic platforms may also affect reproducibility and the applicability of the proposed cutoff.⁸˒⁹

Despite these limitations, the present study provides further evidence supporting the role of RV-FWLS as a quantitative marker of RV myocardial involvement in acute inferior MI. The significant difference between proximal and distal RCA lesions, together with the observed AUC of 0.86, sensitivity of 81.6%, and specificity of 77.2%, suggests that RV-FWLS may complement conventional echocardiographic assessment in identifying patients with proximal RCA disease. Future prospective multicenter studies with standardized strain acquisition, larger sample sizes, external validation of diagnostic thresholds, and longitudinal clinical follow-up are required to determine the reproducibility and prognostic significance of RV-FWLS. Such studies may also clarify whether incorporation of RV-FWLS into routine assessment provides incremental clinical value beyond ECG, conventional echocardiography, and coronary angiography.¹˒⁷˒⁸

6. Clinical Implications

RV-FWLS may be considered a complementary echocardiographic measurement when evaluating patients with acute inferior MI for suspected proximal RCA/RV involvement. It should not replace ECG assessment, coronary angiography or established acute coronary syndrome management. Rather, it may provide additional quantitative information when conventional RV indices are inconclusive.

7. Limitations

• Single-centre observational design and relatively small sample size (n=80).
• Cross-sectional design prevents assessment of temporal changes in RV strain.
• Only patients with adequate echocardiographic image quality were included.
• No longitudinal clinical follow-up was available; therefore, prognostic outcomes could not be evaluated.
• The study did not report interobserver or intraobserver reproducibility of RV-FWLS.
• The proposed RV-FWLS threshold was internally derived and requires external validation.

In patients with acute inferior MI, proximal RCA involvement was associated with significantly less negative RV free-wall longitudinal strain. An RV-FWLS threshold of ≥−16.0% demonstrated 81.6% sensitivity, 77.2% specificity and an AUC of 0.86 for identifying proximal RCA lesions in this cohort. RV-FWLS showed better diagnostic discrimination than TAPSE, RV FAC and tricuspid annular S′. These findings support RV-FWLS as a useful complementary echocardiographic marker, while prospective multicentre studies are needed to validate the threshold and determine its prognostic significance

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