Right ventricular myocardial infarction initial care

Right ventricular myocardial infarction Microchapters
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Overview
Pathophysiology
Pathophysiology of Reperfusion
Gross Pathology
Histopathology
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Differentiating Right ventricular myocardial infarction from other Diseases
Epidemiology and Demographics
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Natural History, Complications and Prognosis
Diagnosis
Diagnostic Criteria
History and Symptoms
Physical Examination
Electrocardiogram
Chest X Ray
Echocardiography or Ultrasound
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Treatment
Initial Care
Pharmacological Reperfusion
Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)
Fibrinolysis
Mechanical Reperfusion
The Importance of Reducing Door-to-Balloon Times
Primary PCI
Adjunctive and Rescue PCI
Rescue PCI
Facilitated PCI
Adjunctive PCI
CABG
Management of Patients Who Were Not Reperfused
Assessing Success of Reperfusion
Antithrombin Therapy
Antithrombin Therapy
Unfractionated Heparin
Low Molecular Weight Heparinoid Therapy
Direct Thrombin Inhibitor Therapy
Factor Xa Inhibition
DVT Prophylaxis
Long Term Anticoagulation
Antiplatelet Agents
Aspirin
Thienopyridine Therapy
Glycoprotein IIbIIIa Inhibition
Other Initial Therapy
Inhibition of the Renin-Angiotensin-Aldosterone System
Magnesium Therapy
Glucose Control
Calcium Channel Blocker Therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

In addition to the reperfusion therapy for STEMI, the acute treatment of right ventricular myocardial infarction is supportive. Volume expansion with normal saline is the primary supportive treatment for the hemodynamic abnormalities of a right ventricular myocardial infarction. Inotropic agents, such as intravenous dopamine, are appropriate in patients whose hypotension is not corrected after 1 L of saline infusion. B-blocker therapy with metoprolol is contraindicated due to bradycardia. Additionally, nitroglycerin is contraindicated in these patients due to risk of hypotension.

Treatment

Initial supportive therapy

• Initial therapy in symptomatic patients is aimed at reversing the decreased filling and right-sided stroke volume while also improving right ventricular function.

Aggressive fluid resuscitation

• Intravenous fluid, usually isotonic saline, should be given to raise the central filling pressure. This is an attempt to maximize forward flow out of the right ventricle, which prevents inappropriate low left-sided filling pressures.
• In most cases, several liters of saline are infused rapidly until there is an increase in the pulmonary capillary wedge pressure to approximately 15 mmHg.
• If central hemodynamic monitoring in not available, 1 - 2 liters of saline can be infused while closely following the blood pressure and urine output and examining the patient for signs of pulmonary congestion.

Avoid drugs which decrease preload

• Systemic cardiac output is dependent upon filling of the left ventricle. In the setting of right ventricular dysfunction and decreased contractility, a reduced preload results sequentially in diminished right sided stroke volume, reduced flow to the left heart, and a fall in cardiac output. As a result, any medication (such as diuretics or nitrates) or any maneuvers that decrease preload should be avoided.

Inotropic stimulation

• When fluid resuscitation is insufficient, inotropic and chronotropic stimulation with dobutamine may increase forward flow and augment cardiac output.
• Dobutamine may also act by reducing pulmonary vascular resistance and therefore right ventricular afterload.
• The initial dose of dobutamine is 5 µg/kg/min and it can be titrated up to 20 µg/kg/min as needed.