Right ventricular myocardial infarction resident survival guide
|Right ventricular myocardial infarctiona|
Resident Survival Guide
Synonyms and Keywords: Approach to right ventricular myocardial infarction, Right ventricular myocardial infarction workup
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.
Life Threatening Causes
STEMI is a life-threatening condition and must be treated as such irrespective of the underlying cause.
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.  
Obtain right-sided precordial leads
>= 1mm ST elevation in lead V4R
Highly suggestive of RVMI
❑ Hemodynamically significant RVMI:
❑ In concomitant LV dysfunction:
❑ Additional hemodynamic changes:
Therapuetic Considerations in Right Ventriculay Myocardial Infarction (RV MI)
❑ May be needed in patients with cardiogenic shock secondary to RV MI:
- Right ventricular myocardial infarction (RV MI) 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 RV MI. These include:
- 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 RV MI 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.
- In patients with RV MI, avoid preload-reducing agents such as nitrates, diuretics, morphine, beta-blockers, and calcium channel blockers.
- "Correction". Circulation. 131 (24): e535. 2015. doi:10.1161/CIR.0000000000000219. PMID 26078378.
- 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.