Right ventricular myocardial infarction resident survival guide

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Right ventricular myocardial infarctiona
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

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

Synonyms and Keywords: Approach to right ventricular myocardial infarction, Right ventricular myocardial infarction workup

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(RV MI) according to the American College of Cardiology and European Society of Cardiology guidelines. [1] [2]

 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 American College of Cardiology and European Society of Cardiology guidelines. [1] [2]


 
 
 
 
 
 
 
 
 
 
 
 
Therapuetic Considerations in Right Ventriculay Myocardial Infarction (RV MI)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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:

Milrinone

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

Do's

Don'ts

References

  1. 1.0 1.1 "Correction". Circulation. 131 (24): e535. 2015. doi:10.1161/CIR.0000000000000219. PMID 26078378.
  2. 2.0 2.1 Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H; et al. (2018). "2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)". Eur Heart J. 39 (2): 119–177. doi:10.1093/eurheartj/ehx393. PMID 28886621.


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