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| {{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | |A01= <div style="float: Center; text-align: Center; width: 20em; padding:1em;"> '''Therapuetic Considerations in [[Right Ventriculay Myocardial Infarction]] ([[RVMI]])'''| | | |}}
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| {{familytree | | | B01 | | | B02 | | | B03 | | B04 | | B05 | | | B06 |B01=<div style="float: Center; text-align: Center; width: 5em; padding:1em;">'''[[Reperfusion]]'''|B02=<div style="float: Center; text-align: Center; width: 5em; padding:1em;">'''Maintenance of [[RV]] [[preload]]'''|B03=<div style="float: center; text-align: center; width: 5em; padding:1em;">'''Decreasing [[RV]] [[afterload]]'''|B04=<div style="float: Center; text-align: Center; width: 5em; padding:1em;">'''Restoring [[Rate]]/[[Rhythm]] and [[AV synchrony]]'''|B05=<div style="float: Center; text-align: Center; width: 5em; padding:1em;">'''Inotropic support'''|B06=<div style="float: Center; text-align: Center; width: 5em; padding:1em;">'''[[Mechanical Circulatory Support]]'''}}
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| {{familytree | | | |!| | | | |!| | | | |!| | | |!| | | |!| | | | |!| | | |}}
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| {{familytree | | | C01 | | | C02 | | | C03 | | C04 | | C05 | | | C06 |C01=<div style="float: Center; text-align: Center; width: 5em; padding:3em;">'''[[Thrmobolytics]]''' <br>'''[[Percutaneous coronary intervention]] ([[PCI]])''' <br>
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| |C02= <div style="float: Center; text-align: left;"> • '''Avoidance of preload-reducing agents''', such as:<br>
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| :❑ [[Nitrates]]
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| :❑ [[Diuretics]]
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| :❑ [[Morphin]]
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| • '''In patients with [[hypotension]] (without [[pulmonary congestion]]):
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| :❑ 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)
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| |C03=<div style="float: Center; text-align: left;"> • '''Systemic or pulmonary [[vasodilators]]:'''<br>
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| :❑ [[Nitrosrusside]]
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| :❑ Inhaled [[nitric oxide]]
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| |C04=<div style="float: Center; text-align: left;"> • '''In patients with [[bradyarrhthmias]]:'''<br>
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| :❑ [[Atropine]]
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| :❑ [[Pacemaker]]
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| • '''In patients with atrioventricular block:'''<br>
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| :❑ Temporary dual-chamber [[pacemaker]]
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| |C05=<div style="float: Center; text-align: left;"> '''In patients with refractory [[hypotension]]:'''<br>
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| :❑ [[Dobutamine]] (along with fluids)
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| :❑ Other [[inotropes]]:
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| * [[Milrinone]]
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| * [[Norepinephrine]]
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| |C06= <div style="float: Center; text-align: left;"> • '''May be needed in patients with [[cardiogenic shock]] secondary to [[RVMI]]''':
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| :❑ Direct RV support
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| :❑ Indirect RV support
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| :❑ Biventricular support}}
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| <br><br>
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| {{familytree/end}}
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| ==Do's==
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| * [[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]].
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| *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:
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| **[[Pulmonary embolism]]
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| **[[Pericarditis]] with [[pericardial tamponade]]
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| *Systemic or pulmonary [[vasodilators]] may be considered in selected patients to reduce [[RV afterload]], thereby improving [[cardiac output]].
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| *In patients with severe [[tricuspid regurgitation]] due to [[RVMI]], replacement of [[tricuspid valve]] or repair of the valve with annuloplasty rings may be considered.
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| *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.
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| *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.
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| ==Don'ts==
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| * In patients with [[RVMI]], avoid preload-reducing agents such as [[nitrates]], [[diuretics]], [[morphine]], [[beta-blockers]], and [[calcium channel blockers]].
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| {{Family tree/start}}
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| {{familytree | A01 | A01= <div style="float: left; text-align: left; width: 35em; padding:1em;"> '''Consider right ventricular MI in case of:'''
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| ❑ [[Hypotension]]<br>
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| ❑ Elevated [[jugular venous pressure]]<br>
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| ❑ Clear lung fields<br>
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| ❑ [[ECG]] changes suggestive of an [[inferior MI]] <br>
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| :❑ ST elevation in leads [[Echocardiogram#Limb Leads|II]], [[Echocardiogram#Limb Leads|III]] and [[Echocardiogram#Limb Leads|aVF]] </div>}}
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| {{familytree | |!| | }}
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| {{familytree | B01 | B01= <div style="float: left; text-align: left; width: 35em; padding:1em;">'''Order a right sided ECG in all patients with ST elevation in leads [[II]], [[III]] and [[aVF]]''' <br>
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| ❑ Clearly label the [[ECG]] as right sided to minimize confusion in the emergency room and cath lab<br>
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| ❑ ST-segment elevation of >1 mm in lead V4R suggests a right ventricular [[MI]]</div>}}
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| {{familytree | |!| | }}
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| {{familytree | C01 | C01=<div style="float: left; text-align: left; width: 35em; padding:1em;">
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| ❑ Do not delay the decision and initiation of [[PCI]] vs [[fibrinolytic therapy]]<br>
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| ❑ Do not administer:
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| :❑ [[Beta blockers]]
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| :❑ [[Nitrates]]
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| :❑ [[Diuretics]]
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| ❑ Increase the [[right ventricle]] load by volume expansion with [[normal saline]] preferably with invasive monitoring
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| :❑ If central hemodynamic monitoring is available, administer normal saline (40 ml/min, up to a total of 2 L, intravenously) until there is an increase in the pulmonary capillary wedge pressure to approximately 15 mmHg <ref name="pmid24222834">{{cite journal| author=Inohara T, Kohsaka S, Fukuda K, Menon V| title=The challenges in the management of right ventricular infarction. | journal=Eur Heart J Acute Cardiovasc Care | year= 2013 | volume= 2 | issue= 3 | pages= 226-34 | pmid=24222834 | doi=10.1177/2048872613490122 | pmc=PMC3821821 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24222834 }} </ref>
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| :❑ If central hemodynamic monitoring in not available, administer normal saline with a close monitoring of the blood pressure </div>}}
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| {{familytree | |!| | }}
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| {{familytree | D01 | D01= <div style="float: left; text-align: left; width: 35em; padding:1em;"> '''If hypotension is not corrected with 1-2 L normal saline:'''
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| ❑ Administer inotropic agents
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| : ❑ [[Norepinephrine|<span style="color: #000000;">Norepinephrine</span>]]
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| :: ❑ Initial dose: 0.5–1.0 μg/min
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| :: ❑ Maximum dose: 30–40 μg/min
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| :: ❑ Titrate to [[SBP|<span style="color: #000000;">SBP</span>]] >90 mm Hg
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| : ❑ [[Dopamine|<span style="color: #000000;">Dopamine</span>]]
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| :: ❑ Cardiac dose: 5.0–10 μg/kg/min
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| :: ❑ Pressor dose: 10–20 μg/kg/min
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| :: ❑ Maximum dose: 20–50 μg/kg/min
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| : ❑ [[Dobutamine|<span style="color: #000000;">Dobutamine</span>]]
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| :: ❑ Usual dose: 2.0–20 μg/kg/min
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| :: ❑ Maximum dose: 40 μg/kg/min
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| :: ❑ Avoid ↑ HR by >10% of baseline
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| : ❑ [[Milrinone|<span style="color: #000000;">Milrinone</span>]]
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| :: ❑ Loading dose: 50 μg/kg (slowly over 10 minutes)
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| :: ❑ Maintenance dose: 0.375–0.75 μg/kg/min
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| ❑ Initiate hemodynamic monitoring with a [[pulmonary catheter]] if possible
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| </div>}}
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| {{Familytree/end}}
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