Right ventricular myocardial infarction resident survival guide: Difference between revisions

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==Overview==
==Overview==
RV infarction is a form of [[ST elevation myocardial infarction]] ([[STEMI]]) and is characterized by the presence of symptoms of [[myocardial ischemia]] associated with persistent [[ST elevation]] on [[electrocardiogram]] in right sided lead V4, and elevated [[cardiac enzymes]], [[hypotension]], signs of elevated right heart filling pressures ([[elevated neck veins]]) in the absence of signs of elevated left heart filling pressures (clear lung fields).  [[Nitrates]], [[diuretics]] and [[beta-blockers]] should not be administered to the patient with an RV MI.
RV infarction is a form of [[ST elevation myocardial infarction]] ([[STEMI]]) and is characterized by the presence of symptoms of [[myocardial ischemia]] associated with persistent [[ST elevation]] on [[electrocardiogram]] in right-sided lead V4 (V4R), and elevated [[cardiac enzymes]], [[hypotension]], signs of elevated right heart filling pressures ([[elevated jugular venous pressure]]) in the absence of signs of elevated left heart filling pressures (clear lung fields).  [[Nitrates]], [[diuretics]] and [[beta-blockers]] should not be administered to the patient with an RV MI.


==Causes==
==Causes==

Revision as of 18:44, 11 August 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Mitra Chitsazan, M.D.[2] Mandana Chitsazan, M.D. [3]

Overview

RV infarction is a form of ST elevation myocardial infarction (STEMI) and is characterized by the presence of symptoms of myocardial ischemia associated with persistent ST elevation on electrocardiogram in right-sided lead V4 (V4R), and elevated cardiac enzymes, hypotension, signs of elevated right heart filling pressures (elevated jugular venous pressure) in the absence of signs of elevated left heart filling pressures (clear lung fields). Nitrates, diuretics and beta-blockers should not be administered to the patient with an RV MI.

Causes

Life Threatening Causes

STEMI is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Right ventricular myocardial infarction(RVMI) according to the American College of Cardiology and European Society of Cardiology guidelines.

 
 
 
 
All patients with acute inferior wall myocardial infarction (ST elevation in leads II, III, aVF)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain right-sided precordial leads
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
>= 1mm ST elevation in lead V4R
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly suggestive of RVMI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
 
Echocardiography
 
Coronary Angiography
 
Hemodynamic study
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Classic triad of:

Hypotension
❑ Elevated JVP
❑ Clear Lungs

Kussmaul sign
Pulsus paradoxus
Tricuspid regurgitation murmur
Atrioventrcicular dissociation
❑ Vagal symptoms:

Bradycardia
❑ Nausea
❑ Vomiting
❑ Diaphoresis
❑ Pallor
 

❑ RV dilatation
❑ Depressed RV systolic function
❑ RV wall akinesia or dyskinesia
❑ RA enlargement
❑ Elevated pulmonary pressures
Pulmonary regurgitation
Tricuspid regurgitation

❑ Increased right atrial pressure
 
Gold standard diagnostic modality

❑ In the majority of RVMI:

❑ The culprit artery: Proximal Right Coronary Artery

❑ Occasionally:

❑ The culprit artery: Left circumflex artery or left anterior descending artery
 

❑ Hemodynamically significant RVMI:

❑ Increased RAP>10 mmHg
❑ RAP to PCWP ratio >0.8 (normal<0.6)
❑ RAP within 5 mmHg of the PCWP
❑ Reduced cardiac index
❑ Disproportionate elevation of right-sided filling pressures: Hallmark of RVMI

❑ In concomitant LV dysfunction:

❑ RAP to PCWP ratio can change

❑ Additional hemodynamic changes:

❑ Prominent Y-descend of the RAP
❑ Drop of the systemic arterial pressure >10 mmHg with inspiration
❑ "Dip and plateau" morphology and equalization of the diastolic filling pressures

Treatment

Shown below is an algorithm summarizing the treatment of Right ventricular myocardial infarction according to the ACC and ESC guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
Therapuetic Considerations in Right Ventriculay Myocardial Infarction (RVMI)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maintenance of RV preload
 
 
Decreasing RV afterload
 
Restoring Rate/Rhythm and AV synchrony
 
Inotropic support
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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/min for up to 2L, to maintain CVP <15 mmHg 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:
 
 
May be needed in patients with cardiogenic shock secondary to RVMI:
❑ Direct RV support
❑ Indirect RV support
❑ Biventricular support

Do's

Don'ts

References


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