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| {{Infobox_Disease | | | __NOTOC__ |
| Name = Myocardial infarction|
| | {| class="infobox" style="float:right;" |
| Image = |
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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}} |
| | {{Right ventricular myocardial infarction}} |
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| OMIM = |
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| MedlinePlus = |
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| {{Right ventricular myocardial infarction}} | | '''For patient information click [[Heart attack (patient information)|here]]''' |
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| | {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com] |
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| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
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| [[Right ventricular myocardial infarction (patient information)|Patient Info]]
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| ==[[Right ventricular myocardial infarction overview|Overview]]== | | ==[[Right ventricular myocardial infarction overview|Overview]]== |
| ==[[Right ventricular myocardial infarction pathophysiology|Pathophysiology]]==
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| ==[[Right ventricular myocardial infarction gross pathology|Gross Pathology]]==
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| ==[[Right ventricular myocardial infarction causes|Causes of Right ventricular myocardial infarction]]==
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| ==[[Right ventricular myocardial infarction differential diagnosis|Differentiating Right ventricular myocardial infarction from other Diseases]]==
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| ==[[Right ventricular myocardial infarction epidemiology and demographics|Epidemiology & Demographics]]==
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| ==[[Right ventricular myocardial infarction risk factors|Risk Factors]]==
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| ==[[Right ventricular myocardial infarction triggers|Triggers]]==
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| ==[[Right ventricular myocardial infarction natural history|Natural History, Complications & Prognosis]]== | | == [[ST elevation myocardial infarction pathophysiology|Pathophysiology]] == |
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| ==Diagnosis==
| | [[ST Elevation Myocardial Infarction: Pathophysiology of Reperfusion|Pathophysiology of Reperfusion]] | [[ST elevation myocardial infarction gross pathology|Gross Pathology]] | [[ST elevation myocardial infarction histopathology|Histopathology]] |
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| ==[[Right ventricular myocardial infarction diagnostic criteria|Diagnostic Criteria]]== | | ==[[Right ventricular myocardial infarction causes|Causes]]== |
| [[Right ventricular myocardial infarction history and symptoms|History & 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 MRI|MRI]][[Right ventricular myocardial infarction CT|CT]] | [[Right ventricular myocardial infarction echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Right ventricular myocardial infarction coronary angiography|Coronary Angiography]]
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| ==Treatment==
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| [[Right ventricular myocardial infarction pre-hospital care|Pre-Hospital Care]] | [[Right ventricular myocardial infarction initial care|Initial Care]]
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| ==[[Right ventricular myocardial infarction secondary prevention|Secondary Prevention]]== | | ==[[Right ventricular myocardial infarction differential diagnosis|Differentiating Right ventricular myocardial infarction from other Diseases]]== |
| === Other Imaging Findings === | | == [[ST elevation myocardial infarction epidemiology and demographics|Epidemiology and Demographics]] == |
| * '''Radionuclide ventriculography and technetium-99m-pyrophosphate scanning'''
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| *:* 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.
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| *:* 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.
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| ==Risk Stratification== | | == [[ST elevation myocardial infarction risk factors|Risk Factors]] == |
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| * 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>
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| * 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.
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| * 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>
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| == 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]] |
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| * 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]].
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| * '''Avoid drugs which decrease [[preload]]'''
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| *:* 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]].
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| * '''[[Inotropic]] stimulation'''
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| *:* 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]].
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| * '''[[Transvenous pacing|Pacing]]'''
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| *:* [[Transvenous pacing|Right ventricular pacing]] may be necessary if the infarction results in [[complete heart block]] or loss of AV synchrony.
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| * '''[[Reperfusion]]'''
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| *:* 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>
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| 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]] |
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| * 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]] |
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| == 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}}
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| ==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]]
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| * [http://www.nlm.nih.gov/medlineplus/heartattack.html Heart Attack] - overview of resources from [[MedlinePlus]].
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| * [http://ww2.heartandstroke.ca/Page.asp?PageID=1975&ArticleID=5288 Heart Attack Warning Signals] from the Heart and Stroke Foundation of Canada
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| * [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
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| * [http://www.stemisystems.org/ STEMI Systems] - Articles, profiles, and reviews of the latest publications involved in STEMI care. Quarterly newsletter.
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| * [http://www.americanheart.org/heartattack American Heart Association's Heart Attack web site] - Information and resources for preventing, recognizing and treating heart attack.
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| {{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]] |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
