The acute marginal artery is a branch of the right coronary artery arising from the acute margin (right border) of the heart as the RCA curves around the right atrioventricular groove. It supplies the right ventricular free wall anterior surface. In RCA occlusion proximal to the acute marginal branch, right ventricular infarction (RVMI) develops, producing the clinical triad of hypotension, elevated JVP, and clear lungs — a haemodynamic pattern distinct from left ventricular MI.
The acute marginal artery is the critical branch determining the extent of right ventricular territory threatened by RCA occlusion. Proximal RCA occlusion (before the acute marginal takeoff) produces both inferior wall LVMI and RVMI; distal occlusion spares the RV. RVMI requires specific management — preload maintenance (IV fluids), avoidance of nitrates (which reduce preload and worsen RVMI), and reperfusion priority. Right precordial leads (V3R, V4R) on the 12-lead ECG detect RVMI by showing ST elevation in V4R.
Proximal RCA occlusion before the acute marginal artery produces right ventricular infarction alongside inferior LVMI, presenting with the triad of hypotension, elevated JVP, and clear lung fields; the paradoxical response to nitrates (profound hypotension) requires IV fluid loading to maintain RV preload and primary PCI of the culprit RCA lesion for reperfusion.
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