Sandbox:Mitra

Therapuetic Considerations in RVMI

Reperfusion

Maintenance of RV preload

Decreased RV afterload

Restoring Rate/Rhythm and AV synchrony

Inotropic support

Mechanical Circulatory Support

•Thrmobolytics •Percutaneous coronary intervention (PCI)

• Avoidance of preload reducing agents, such as: ❑Nitrates ❑Diuretics ❑Morphin • In patients with hypotension (without pulmonary congestion): ❑ Intravenous administration of Fluids (N/S 0.9% at 40mL for 2L, to maintain CVP <15mmHg and PCWP between 18-24 mmHg)

• Systemic or pulmonary vasodilators: ❑Nitrosrusside ❑Inhaled nitric oxide

• In patients with bradyarrhthmias: ❑Atropine ❑Pacemaker • In patients with atrioventricular block: ❑Temporary dual-chamber pacemaker

In patients with refractory hypotension: ❑Dobutamine (along with fluids) ❑Other inotropes: milrinone norepinephrine

• May be needed in patients with cardiogenic shock secondary to RVMI: ❑Direct RV support ❑Indirect RV support ❑Biventricular support

Do's

• Right ventricular myocardial infarction (RVMI) should be ruled out in all patients presenting with acute inferior wall myocardial infarction, in particular in patients with hypotension.

• In patients presenting with chest pain and clinical findings of hypotension, elevated JVP and clear lung fields, consider the differential diagnoses of RVMI. These include:
  • Pulmonary embolism
  • Pericarditis with pericardial tamponade

• Systemic or pulmonary vasodilators may be considered in selected patients to reduce RV afterload, thereby improving cardiac output.

• In patients with severe tricuspid regurgitation due to RVMI, replacement of tricuspid valve or repair of the valve with annuloplasty rings may be considered.

• In patients with RVMI who have unexplained hypoxemia despite administration of 100% oxygen, right-to-left shunting -through a patent foramen ovale or atrial septal defect-, caused by the disproportionate elevation in right-sided filling pressures compared to the normal or slightly increased left-sided filling pressures should be considered.

• Patients with extensive necrosis due to RVMI may be at higher risk of right ventricular perforation during interventional procedures. Right ventricular catheterization or pacemaker insertion should be performed with great care in these patients.

Don'ts

• In patients with RVMI, avoid preload-reducing agents such as nitrates, diuretics, morphine, beta-blockers, and calcium channel blockers.