Right ventricular myocardial infarction: Difference between revisions

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{{Infobox_Disease |
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  Name          = Myocardial infarction|
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| [[File:Siren.gif|30px|link=Right ventricular myocardial infarction resident survival guide]]|| <br> || <br>
  DiseasesDB    = 8664 |
| [[Right ventricular myocardial infarction resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
  ICD10          = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} |
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  ICD9          = {{ICD9|410}} |
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{{Right ventricular myocardial infarction}}
{{Right ventricular myocardial infarction}}


{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
'''For patient information click [[Heart attack (patient information)|here]]'''
 
==erview == 
 
[[Acute myocardial infarction]] involving only the free wall of the [[right ventricle]] is a rare event <ref>Anderson, HR, Falk, E, Nielsen, D. Right ventricular infarction: Frequency, size, and topography in coronary heart disease. J Am Coll Cardiol 1987; 10:1223. PMID 3680789</ref>  More commonly, [[Right ventricular myocardial infarction|right ventricular infarction]] is associated with infarction of the inferior wall of the left ventricle, occurring in more than one-third of such cases <ref>Anderson, HR, Falk, E, Nielsen, D. Right ventricular infarction: Frequency, size, and topography in coronary heart disease. J Am Coll Cardiol 1987; 10:1223. PMID 3680789</ref> <ref>Isner, JM, Roberts, WC. Right ventricular infarction complicating left ventricular infarction secondary to coronary artery disease: frequency, location, associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction. Am J Cardiol 1978; 42:885. PMID 153103</ref> <ref>Isner, JM. Right ventricular myocardial infarction. JAMA 1988; 259:712. PMID 3275819</ref>  <ref>Williams, JF. Right ventricular infarction. Clin Cardiol 1990; 13:309. PMID 2189611</ref> <ref>Cabin, HS, Clubb, S, Wackers FJ, et al. Right ventricular myocardial infarction with anterior wall left ventricular infarction: an autopsy study. Am Heart J 1987; 113:16. PMID 3799430</ref> <ref>Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631</ref> <ref>Setaro, JF, Cabin, HS. Right ventricular infarction. Cardiol Clin 1992; 10:69. PMID 1739961</ref> <ref>Cohn, JN. Right ventricular infarction revisited. Am J Cardiol 1979; 43:666. PMID 420117</ref> <ref>Wackers, FJ, Lie, KI, Sokole, EB, et al. Prevalence of right ventricular involvement in inferior wall infarction associated with myocardial imaging with thallium-201 and technetium-99m pyrophosphate. Am J Cardiol 1978; 42:358. PMID 210648</ref>, even when thrombolytic therapy is given <ref>Zeymer, U, Neuhaus, K-L, Wegscheider, K, et al. Effects of thrombolytic therapy in acute inferior myocardial infarction with and without right ventricular involvement. J Am Coll Cardiol 1998; 32:876. PMID 9768705</ref>.
 
One study of 113 patients with a first acute inferior wall infarction reported that the presence of preinfarction angina within 72 hours of the infarction was associated with a reduction in the incidence of right ventricular infarction (odds ratio 0.2) and combined hypotension and shock (odds ratio 0.1) <ref>Shiraki, H, Yoshikawa, T, Anzai, T, et al. Association between preinfarction angina and a lower risk of right ventricular infarction. N Engl J Med 1998; 338:941. PMID 9521981</ref>. This is possibly the result of ischemic preconditioning.
 
* Ninety percent of [[Right ventricular myocardial infarction|right ventricular infarcts]] result from occlusion of the proximal right coronary artery, while another 5 to 10 percent arise after occlusion of the left anterior descending artery <ref>Isner, JM, Roberts, WC. Right ventricular infarction complicating left ventricular infarction secondary to coronary artery disease: frequency, location, associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction. Am J Cardiol 1978; 42:885.PMID 153103</ref> <ref>Isner, JM. Right ventricular myocardial infarction. JAMA 1988; 259:712. PMID 3275819 </ref> <ref>Williams, JF. Right ventricular infarction. Clin Cardiol 1990; 13:309. PMID 2189611</ref> <ref>Cabin, HS, Clubb, S, Wackers FJ, et al. Right ventricular myocardial infarction with anterior wall left ventricular infarction: an autopsy study. Am Heart J 1987; 113:16. PMID 3799430</ref>
 
Although more than one-third of cases are clinically silent <ref>Wackers, FJ, Lie, KI, Sokole, EB, et al. Prevalence of right ventricular involvement in inferior wall infarction associated with myocardial imaging with thallium-201 and technetium-99m pyrophosphate. Am J Cardiol 1978; 42:358. PMID 210648</ref>, the presence of [[Right ventricular myocardial infarction|right ventricular infarction]] often has important implications for both management and prognosis.
 
== Differential diagnosis of conditions to distinguish from right ventricular infarction==
 
* [[Acute pericarditis]]
* [[Pneumothorax]]
* [[Pulmonary Embolism]]
* [[Hypertrophic Cardiomyopathy]]
* [[Restrictive cardiomyopathy]]
* [[Tricuspid Regurgitation]]
* [[Cor Pulmonale]]
* [[Constrictive pericarditis]]
* [[Endomyocardial fibrosis]]
* [[Primary pulmonary hypertension]]
* [[Secondary pulmonary hypertension]]
 
== Diagnosis ==
 
* Because the [[right ventricle]] has a remarkable tendency to recover function rapidly, diagnostic tests are most reliable when performed soon after presentation. Clinical suspicion and a careful physical examination demonstrating the signs are the first step.
 
<div align="left">
<gallery heights="200" widths="200">
Image:ECG electrodes RVMI.jpg|Places of chest leads during EKG recording for suspected RVMI.
</gallery>
</div>
 
In general, requirements of diagnosing a right ventricular myocardial infarction as follow:
 
* Right-sided ST segment elevation of > 1 mm (leads V<sub>3</sub>R through V<sub>6</sub>R)
* 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)
 
=== History and Symptoms ===
 
* Ischemia or infarction of the right ventricle results in decreased right ventricular compliance, reduced filling, and diminished right-sided stroke volume with concomitant right venticular dilation and alteration in septal curvature <ref>Brookes, C, Ravn, H, White, P, et al. Acute right ventricular dilatation in response to ischemia significantly impairs left ventricular systolic performance. Circulation 1999; 100:761. PMID 10449700.</ref> These hemodynamic and geometric changes lead to decreased left ventricular filling and contractile function with a concomitant fall in cardiac output <ref>Williams, JF. Right ventricular infarction. Clin Cardiol 1990; 13:309. PMID 2189611</ref> <ref>Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631</ref> <ref>Setaro, JF, Cabin, HS. Right ventricular infarction. Cardiol Clin 1992; 10:69. PMID 1739961</ref> <ref>Cohn, JN. Right ventricular infarction revisited. Am J Cardiol 1979; 43:666. PMID 420117</ref> <ref>Zeymer, U, Neuhaus, K-L, Wegscheider, K, et al. Effects of thrombolytic therapy in acute inferior myocardial infarction with and without right ventricular involvement. J Am Coll Cardiol 1998; 32:876. PMID 9768705</ref> <ref>Shiraki, H, Yoshikawa, T, Anzai, T, et al. Association between preinfarction angina and a lower risk of right ventricular infarction. N Engl J Med 1998; 338:941. PMID 9521981</ref>. The net effect is that left-sided filling pressures may be below normal despite clinical signs of high pressure on the right side. This disparity has important implications for therapy (see below).
 
* Patients with hemodynamically significant right ventricular infarction typically present with hypotension, jugular vein distention, and occasionally shock, all in the presence of clear lung fields. Valvular insufficiency can also occur, leading to tricuspid regurgitation. These findings are in contrast to the frequent pulmonary congestion, third or fourth heart sounds, and mitral regurgitation with left ventricular infarcts.
 
=== Laboratory Studies ===
 
* The diagnosis of [[Right ventricular myocardial infarction|right ventricular infarction]] is suspected in the appropriate clinical setting when the right atrial pressure exceeds 10 mmHg and the ratio of right atrial pressure to pulmonary capillary wedge pressure exceeds 0.8 (normal mean value less than 0.6)<ref>Isner, JM. Right ventricular myocardial infarction. JAMA 1988; 259:712.PMID 3275819</ref> <ref>Williams, JF. Right ventricular infarction. Clin Cardiol 1990; 13:309. PMID 2189611</ref> <ref>Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631</ref> <ref>Cohn, JN. Right ventricular infarction revisited. Am J Cardiol 1979; 43:666. PMID 420117</ref> <ref>Dell'Italia, LJ, Starling, MR, Crawford, MH, et al. Right ventricular infarction: Identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. J Am Coll Cardiol 1984; 4:931. PMID 6092446</ref>.
 
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 <ref>Dell'Italia, LJ, Starling, MR, Crawford, MH, et al. Right ventricular infarction: Identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. J Am Coll Cardiol 1984; 4:931. PMID 6092446</ref>
 
=== Electrocardiogram ===
 
* In addition to evidence of an acute [[Acute myocardial infarction|inferior]] or [[Acute myocardial infarction|inferoposterior]] [[myocardial infarction]], the ECG may demonstrate > or =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 <ref>Isner, JM. Right ventricular myocardial infarction. JAMA 1988; 259:712. PMID 3275819</ref>  <ref>Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631</ref> <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875</ref> 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 <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875.</ref>
 
[[Pulmonary embolism]], [[pericarditis]], and [[Acute myocardial infarction||anteroseptal myocardial infarction]] also cause elevation of the [[ST segment]] in the right-sided precordial leads. As a result, an electrocardiographic diagnosis of [[Right ventricular myocardial infarction|right ventricular infarction]] cannot be made when one of these conditions is present <ref>Williams, JF. Right ventricular infarction. Clin Cardiol 1990; 13:309. PMID 2189611</ref> <ref>Kahn, JK, Bernstein, M, Bengston, JR. Isolated right ventricular myocardial infarction. Ann Intern Med 1993; 118:708. PMID 8460858</ref>


<div align="left">
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com]
<gallery heights="225" widths="225">
Image:Casus2_2.jpg|12 lead ECG shows Inferior MI + Right ventricular MI
Image:Casus2_1.jpg|ST elevation at V4R on same patient's EKG (obtained from right precordial leads).
</gallery>
</div>


==[[Right ventricular myocardial infarction overview|Overview]]==


<div align="left">
== [[ST elevation myocardial infarction pathophysiology|Pathophysiology]] ==
<gallery heights="225" widths="225">
Image:RV MI.jpg|Right ventricular MI
Image:RVinfarct.jpg|Right ventricular MI
</gallery>
</div>


===Echocardiography===
[[ST Elevation Myocardial Infarction: Pathophysiology of Reperfusion|Pathophysiology of Reperfusion]] |  [[ST elevation myocardial infarction gross pathology|Gross Pathology]] | [[ST elevation myocardial infarction histopathology|Histopathology]]


* Echocardiography may be limited in [[Right ventricular myocardial infarction|right ventricular infarction]] by suboptimal views of the right ventricle. In addition, interpretation of right ventricular function may be affected by coexistent pulmonary disease (such as [[Chronic obstructive pulmonary disease|obstructive lung disease]] or [[pulmonary embolism]]).
==[[Right ventricular myocardial infarction causes|Causes]]==
* Despite these limitations, [[echocardiography]] is often a useful test that can be performed at the bedside when the diagnosis of [[Right ventricular myocardial infarction|right ventricular infarction]] is suspected. Right ventricular size and function and the degree (if any) of [[tricuspid insufficiency]] can all be evaluated <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875</ref> Useful information concerning left-sided structures and function can also be obtained <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875</ref><ref>Kahn, JK, Bernstein, M, Bengston, JR. Isolated right ventricular myocardial infarction. Ann Intern Med 1993; 118:708. PMID 8460858</ref>
* Right ventricular peak systolic pressure may be estimated from the Doppler signal of [[tricuspid insufficiency]] using the modified Bernoulli equation:
*:* Right ventricular peak systolic pressure  =   RAP  +  4V(2)
*:*:* Where RAP equals the estimated right atrial pressure based upon examination of the jugular neck veins, V is the velocity of the [[tricuspid insufficiency]] jet by Doppler ultrasonography, and V(2) refers to V squared. A right ventricular peak systolic pressure above  30 mmHg is considered elevated. Mild elevation is 30 to 45 mmHg, moderate 45 to 60 mmHg, and severe is greater than 60 mmHg.
* In the absence of [[pulmonary stenosis]] (which is rare), right ventricular systolic pressure is equal to the pulmonary artery systolic pressure. As a result, this equation is useful for estimating the presence and severity of [[pulmonary hypertension]]. When significant [[pulmonary artery hypertension]] (>45 to 50 mmHg) complicates [[Right ventricular myocardial infarction|right ventricular infarction]], the failing right ventricle may be unable to pump blood from the right heart into the left heart. In this setting, a positive inotropic agent such as [[dobutamine]] may be effective in augmenting forward flow while also decreasing [[pulmonary vascular resistance]] and right ventricular overload (see below)


=== Other Imaging Findings ===
==[[Right ventricular myocardial infarction differential diagnosis|Differentiating Right ventricular myocardial infarction from other Diseases]]==
* '''Radionuclide ventriculography and technetium-99m-pyrophosphate scanning'''
== [[ST elevation myocardial infarction epidemiology and demographics|Epidemiology and Demographics]] ==
*:* These techniques have acceptable sensitivities and specificities for making a diagnosis of [[Right ventricular myocardial infarction|right ventricular infarction]] <ref>Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631</ref> <ref>Cohn, JN. Right ventricular infarction revisited. Am J Cardiol 1979; 43:666. PMID 420117</ref> <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875</ref> <ref>Kahn, JK, Bernstein, M, Bengston, JR. Isolated right ventricular myocardial infarction. Ann Intern Med 1993; 118:708. PMID 8460858</ref>  Radionuclide angiography can detect wall motion abnormalities and hypoperfusion in the affected right ventricle. It can also be used to quantitate both left and right ventricular ejection fractions. Technetium scanning, on the other hand, is particularly useful for late diagnosis, as it shows areas of necrotic or dying myocardium.
*:* However, both methods are cumbersome and time consuming. They are also frequently difficult to perform at the bedside, particularly when the patient is unstable in the intensive care unit and nuclear cardiology equipment is not readily portable. Thus, these tests are best performed later in the course to further quantify the degree of right ventricular infarction and dysfunction.


==Risk Stratification==  
== [[ST elevation myocardial infarction risk factors|Risk Factors]] ==


* The presence of [[Right ventricular myocardial infarction|right ventricular infarction]] adversely affects the early prognosis. One study, for example, evaluated 200 consecutive patients with acute inferior myocardial infarction  <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875</ref> Those with ST elevation in V4R had an almost eight-fold increase in in-hospital mortality (31 versus 6 percent) and morbidity when compared to those without changes in V4R.
==[[Right ventricular myocardial infarction natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
* Elderly patients who have right ventricular involvement with an [[Acute myocardial infarction|inferior wall myocardial infarction]] are at particularly high risk. In a study of 198 patients ≥75 years of age, right ventricular involvement was associated with an in-hospital mortality of 47 percent compared to a 10 percent mortality in the absence of right ventricular involvement <ref>Bueno, H, Lopez-Palop, R, Bermejo, J, et al. In-hospital outcome of elderly patients with acute inferior myocardial infarction and right ventricular involvement. Circulation 1997; 96:436. PMID 9788824</ref>
* For patients who survive an acute [[Right ventricular myocardial infarction|right ventricular infarction]], however, the prognosis is generally good. As an example, among 522 patients with an [[Acute myocardial infarction|inferior wall infarction]] who were treated with a thrombolytic agent and hirudin or heparin in the HIT-4 study, 32 percent had right ventricular involvement and these patients had a higher 30 day mortality when compared to those without right ventricular involvement (5.9 versus 2.5 percent) <ref>Zeymer, U, Neuhaus, K-L, Wegscheider, K, et al. Effects of thrombolytic therapy in acute inferior myocardial infarction with and without right ventricular involvement. J Am Coll Cardiol 1998; 32:876. PMID 9768705</ref>  However, this was related to a larger infarct size rather than right ventricular involvement; right ventricular involvement was not an independent predictor of survival.
* The right ventricle frequently recovers the majority of its function, probably due at least in part to decreased oxygen demand of the thin-walled right ventricle <ref>Williams, JF. Right ventricular infarction. Clin Cardiol 1990; 13:309. PMID 2189611</ref> <ref>Cohn, JN. Right ventricular infarction revisited. Am J Cardiol 1979; 43:666. PMID 420117</ref>. These patients may, however, have a more frequent requirement for a permanent [[pacemaker]]. <ref>Zehender, M, Kasper, W, Kauder, E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981. PMID 8450875</ref>


== Treatment ==
==Diagnosis==
[[Right ventricular myocardial infarction diagnostic criteria|Diagnostic Criteria]] | [[Right ventricular myocardial infarction history and symptoms|History and Symptoms]] | [[Right ventricular myocardial infarction physical examination|Physical Examination]] | [[Right ventricular myocardial infarction electrocardiogram|Electrocardiogram]] | [[Right ventricular myocardial infarction chest x ray|Chest X Ray]] | [[Right ventricular myocardial infarction echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[ST elevation myocardial infarction coronary angiography|Coronary Angiography]] | [[Right ventricular myocardial infarction other imaging findings|Other Imaging Findings]]


* Therapy in '''symptomatic patients''' is aimed at reversing the decreased filling and right-sided stroke volume and at improving right ventricular function.
==Treatment==
* '''Aggressive fluid resuscitation'''
====[[Right ventricular myocardial infarction initial care|Initial Care]]====
*:* Intravenous fluid, usually isotonic saline, should be given to raise the central filling pressure in an attempt to maximize forward flow out of the right ventricle, thereby preventing inappropriate low left-sided filling pressures <ref>Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631</ref> <ref>Dell'Italia, LJ, Starling, MR, Crawford, MH, et al. Right ventricular infarction: Identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. J Am Coll Cardiol 1984; 4:931. PMID 6092446</ref> In most cases, several liters of saline are infused rapidly until there is an increase in the [[pulmonary capillary wedge pressure]] to approximately 15 mmHg. If central hemodynamic monitoring in not available, one to two liters of saline can be infused while closely following the blood pressure and urine output and examining the patient for [[pulmonary edema|signs of pulmonary congestion]].
* '''Avoid drugs which decrease [[preload]]'''
*:* Systemic [[cardiac output]] is dependent upon filling of the left ventricle. In the setting of right ventricular dysfunction and decreased contractility, reduced preload results sequentially in diminished right sided stroke volume, reduced flow to the left heart, and a fall in [[cardiac output]]. As a result, any medication (such as [[diuretics]] or [[nitrates]]) or maneuver which decreases [[preload]] should be avoided. Even an increase in vagal tone caused by insertion of a bladder catheter can acutely decrease [[preload]] and lead to [[cardiogenic shock]].
* '''[[Inotropic]] stimulation'''
*:* When fluid resuscitation is insufficient, [[inotropic]] and [[chronotropic]] stimulation with [[dobutamine]] may increase forward flow and augment [[cardiac output]]. [[Dobutamine]] may also act by reducing [[pulmonary vascular resistance]] and therefore right ventricular [[afterload]]. The usual starting dose is 5 µg/kg per min. The dose is titrated up to 20 µg/kg per min depending upon the clinical response. However, frequent ventricular ectopy and [[ventricular tachycardia]] may limit the use of doses above 10 µg/kg per min. Additionally, since [[dobutamine]] decreases [[peripheral vascular resistance]], higher doses may cause [[hypotension]] as a result of an inadequate rise in [[cardiac output]] to match the decrease in [[systemic vascular resistance]].
* '''[[Transvenous pacing|Pacing]]'''
*:* [[Transvenous pacing|Right ventricular pacing]] may be necessary if the infarction results in [[complete heart block]] or loss of AV synchrony.
* '''[[Reperfusion]]'''
*:* Early [[reperfusion]] using either [[thrombolytic therapy]] or direct angioplasty is useful for preserving both right and left ventricular function and results in decreased mortality and morbidity <ref>Goldberger, JJ, Himelman, RB, Wolfe, CL, Schiller, NB. Right ventricular infarction: Recognition and assessment of its hemodynamic significance by two-dimensional echocardiography. J Am Soc Echocardiogr 1991; 4:140. PMID 2036226</ref> <ref>Berger, PB, Ruocco, NA, Ryan, TJ, et al. Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thrombolytic therapy. Am J Cardiol 1993; 71:1148. PMID 8097614</ref> <ref>Kinn, JW, Aljuni, SC, Samyn, JG, et al. Rapid hemodynamic improvement after reperfusion during right ventricular infarction. J Am Coll Cardiol 1995; 26:1230. PMID 7594036 </ref> <ref>Bowers, TR, O'Neill, WW, Grines, C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998; 338:933. PMID 9521980 </ref>


The indications for these modalities are similar to those in [[Acute myocardial infarction|left ventricular infarction]]. Patients in whom [[reperfusion]] is achieved typically show a dramatic improvement in the hemodynamic profile within 24 hours <ref>Kinn, JW, Aljuni, SC, Samyn, JG, et al. Rapid hemodynamic improvement after reperfusion during right ventricular infarction. J Am Coll Cardiol 1995; 26:1230. PMID 7594036 </ref> <ref>Bowers, TR, O'Neill, WW, Grines, C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998; 338:933. PMID 9521980 </ref>
'''Pharmacologic Reperfusion''': [[ST elevation myocardial infarction reperfusion therapy|Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)]] | [[ST elevation myocardial infarction fibrinolytic therapy|Fibrinolysis]]


* As an example, one study of 53 patients reported that [[primary angioplasty]] resulted in normal flow in the [[right coronary artery]] and its major right ventricular branches in 77 percent of patients; [[reperfusion]] was associated with prompt and striking recovery of right ventricular function at three days <ref>Bowers, TR, O'Neill, WW, Grines, C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998; 338:933. PMID 9521980 </ref> Failure to reperfuse resulted in lack of functional recovery, persistent [[hypotension]], low [[cardiac output]], and a higher mortality rate (58 versus 2 percent for those with successful [[reperfusion]], p=0.001).
'''Mechanical Reperfusion''': [[Door-to-Balloon|The Importance of Reducing Door-to-Balloon Times]] | [[ST elevation myocardial infarction primary percutaneous coronary intervention|Primary PCI]] | [[ST elevation myocardial infarction percutaneous coronary intervention following fibrinolytic administration|Adjunctive and Rescue PCI]] | [[ST elevation myocardial infarction rescue percutaneous coronary intervention|Rescue PCI]] |
[[ST elevation myocardial infarction facilitated percutaneous coronary intervention|Facilitated PCI]] |
[[ST Elevation Myocardial Infarction Adjunctive Percutaneous Coronary Intervention|Adjunctive PCI]] |
[[ST elevation myocardial infarction coronary artery bypass grafting|CABG]] | [[ST elevation myocardial infarction management of patients who were not reperfused|Management of Patients Who Were Not Reperfused]] | [[ST elevation myocardial infarction assessing success of reperfusion|Assessing Success of Reperfusion]]


== References ==
'''Antithrombin Therapy''': [[ST elevation myocardial infarction anticoagulant and antithrombotic therapy|Antithrombin Therapy]] | [[ST elevation myocardial infarction anticoagulant and antithrombotic therapy#Unfractionated Heparin|Unfractionated Heparin]] | [[ST elevation myocardial infarction anticoagulant and antithrombotic therapy#Enoxaparin|Low Molecular Weight Heparinoid Therapy]] | [[ST elevation myocardial infarction anticoagulant and antithrombotic therapy#Bivalirudin|Direct Thrombin Inhibitor Therapy]] | [[ST elevation myocardial infarction anticoagulant and antithrombotic therapy#Fondaparinux|Factor Xa Inhibition]] | [[ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation|DVT Prophylaxis]] | [[ST elevation myocardial infarction deep vein thrombosis prophylaxis and anticoagulation|Long Term Anticoagulation]]
{{Reflist|2}}


==External links==
'''Antiplatelet Agents''': [[ST elevation myocardial infarction aspirin therapy|Aspirin]] | [[ST elevation myocardial infarction thienopyridine therapy|Thienopyridine Therapy]] | [[ST elevation myocardial infarction glycoprotein IIbIIIa inhibition|Glycoprotein IIbIIIa Inhibition]]
* [http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack] - based on information of the [[Framingham Heart Study]], from the United States [[National Heart, Lung and Blood Institute]]
* [http://www.nlm.nih.gov/medlineplus/heartattack.html Heart Attack] - overview of resources from [[MedlinePlus]].
* [http://ww2.heartandstroke.ca/Page.asp?PageID=1975&ArticleID=5288 Heart Attack Warning Signals] from the Heart and Stroke Foundation of Canada
* [http://www.regionalpci-stemi.org/index.html Regional PCI for STEMI Resource Center] - Evidence based online resource center for the development of regional PCI networks for acute STEMI
* [http://www.stemisystems.org/ STEMI Systems] - Articles, profiles, and reviews of the latest publications involved in STEMI care. Quarterly newsletter.
* [http://www.americanheart.org/heartattack American Heart Association's Heart Attack web site] - Information and resources for preventing, recognizing and treating heart attack.


{{STEMI}}
'''Other Initial Therapy''': [[ST elevation myocardial infarction inhibition of the renin-angiotensin-aldosterone system at discharge|Inhibition of the Renin-Angiotensin-Aldosterone System]] | [[ST elevation myocardial infarction magnesium therapy|Magnesium Therapy]] |  [[ST elevation myocardial infarction glucose control|Glucose Control]] | [[ST elevation myocardial infarction calcium channel blocker therapy|Calcium Channel Blocker Therapy]]


[[Category:Cardiology]]
[[Category:Cardiology]]

Latest revision as of 14:58, 17 March 2014



Resident
Survival
Guide

Right ventricular myocardial infarction Microchapters

Home

Overview

Pathophysiology

Pathophysiology of Reperfusion
Gross Pathology
Histopathology

Causes

Differentiating Right ventricular myocardial infarction from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Electrocardiogram

Chest X Ray

Echocardiography or Ultrasound

Coronary Angiography

Other Imaging Findings

Treatment

Initial Care

Pharmacological Reperfusion

Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)
Fibrinolysis

Mechanical Reperfusion

The Importance of Reducing Door-to-Balloon Times
Primary PCI
Adjunctive and Rescue PCI
Rescue PCI
Facilitated PCI
Adjunctive PCI
CABG
Management of Patients Who Were Not Reperfused
Assessing Success of Reperfusion

Antithrombin Therapy

Antithrombin Therapy
Unfractionated Heparin
Low Molecular Weight Heparinoid Therapy
Direct Thrombin Inhibitor Therapy
Factor Xa Inhibition
DVT Prophylaxis
Long Term Anticoagulation

Antiplatelet Agents

Aspirin
Thienopyridine Therapy
Glycoprotein IIbIIIa Inhibition

Other Initial Therapy

Inhibition of the Renin-Angiotensin-Aldosterone System
Magnesium Therapy
Glucose Control
Calcium Channel Blocker Therapy

Right ventricular myocardial infarction On the Web

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Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

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FDA on Right ventricular myocardial infarction

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Right ventricular myocardial infarction in the news

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For patient information click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Priyamvada Singh, M.D. [3]

Overview

Pathophysiology

Pathophysiology of Reperfusion | Gross Pathology | Histopathology

Causes

Differentiating Right ventricular myocardial infarction from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria | History and Symptoms | Physical Examination | Electrocardiogram | Chest X Ray | Echocardiography or Ultrasound | Coronary Angiography | Other Imaging Findings

Treatment

Initial Care

Pharmacologic Reperfusion: Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI) | Fibrinolysis

Mechanical Reperfusion: The Importance of Reducing Door-to-Balloon Times | Primary PCI | Adjunctive and Rescue PCI | Rescue PCI | Facilitated PCI | Adjunctive PCI | CABG | Management of Patients Who Were Not Reperfused | Assessing Success of Reperfusion

Antithrombin Therapy: Antithrombin Therapy | Unfractionated Heparin | Low Molecular Weight Heparinoid Therapy | Direct Thrombin Inhibitor Therapy | Factor Xa Inhibition | DVT Prophylaxis | Long Term Anticoagulation

Antiplatelet Agents: Aspirin | Thienopyridine Therapy | Glycoprotein IIbIIIa Inhibition

Other Initial Therapy: Inhibition of the Renin-Angiotensin-Aldosterone System | Magnesium Therapy | Glucose Control | Calcium Channel Blocker Therapy


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