Right ventricular myocardial infarction diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

This diagnosis of right ventricular myocardial infarction should be considered in patients with the clinical triad of hypotension, clear lung fields, and jugular venous distention. The diagnosis can be made using a right-sided electrocardiogram, on which ST-segment elevation in leads V3R and V4R is found.

Diagnostic Criteria

In general, requirements of diagnosing a right ventricular myocardial infarction are as follows:

• Right-sided ST segment elevation of > 1 mm (leads V₃R through V₆R).
• Right ventricular asynergy as demonstrated by echocardiography or cardiac nuclear imaging.
• Mean right arterial pressure of ≥ 10 mm Hg or a < 5 mm Hg difference from mean pulmonary capillary wedge pressure (equivalent to left atrial pressure).
• Non-compliant right atrial pressure waveform pattern (steep and deep x and y descents)

Other Diagnostic Criteria

• Clinical triad of hypotension, clear lung fields, and jugular venous distention.
• Electrocardiogram
  • In addition to evidence of an acute inferior or inferoposterior myocardial infarction, the ECG may demonstrate ≥ 1 mm of doming ST elevation in the right sided precordial leads V4R to V6R.
  • Right sided ST elevation, particularly in V4R, is indicative of acute right ventricular injury and correlates closely with occlusion of the proximal right coronary artery.
  • In one report of patients with acute inferior infarction, for example, ST elevation in V4R had 88 percent sensitivity and 78 percent specificity for concurrent right ventricular infarction.
  • Pulmonary embolism, pericarditis, and anteroseptal myocardial infarction also causes elevation of the ST segment in the right-sided precordial leads. As a result, an electrocardiographic diagnosis of right ventricular infarction cannot be made when one of these conditions is present.

• The right atrial pressure exceeds 10 mm Hg and the ratio of right atrial pressure to pulmonary capillary wedge pressure exceeds 0.8 (normal mean value less than 0.6).

• However, these findings may not be present in patients with only minimal right ventricular dysfunction or in those with intravascular volume depletion. In the latter setting, a volume challenge may unmask the signs of right ventricular infarction.