Right ventricular myocardial infarction resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Mitra Chitsazan, M.D.[2] Mandana Chitsazan, M.D. [3]

Overview

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, and elevated cardiac enzymes, hypotension, signs of elevated right heart filling pressures (elevated neck veins) 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.

Causes

Life Threatening Causes

STEMI is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Treatment

Shown below is an algorithm summarizing the treatment of Right ventricular myocardial infarction according to the ACC and ESC guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
Therapuetic Considerations in Right Ventriculay Myocardial Infarction (RVMI)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maintenance of RV preload
 
 
Decreasing RV afterload
 
 
Restoring Rate/Rhythm and AV synchrony
 
Inotropic support
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Avoidance of preload-reducing agents, such as:
Nitrates
Diuretics
Morphin

In patients with hypotension (without pulmonary congestion):

❑ 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)
 
 
Systemic or pulmonary vasodilators:
Nitrosrusside
❑ Inhaled nitric oxide
 
 
In patients with bradyarrhthmias:
Atropine
Pacemaker

In patients with atrioventricular block:

❑ Temporary dual-chamber pacemaker
 
In patients with refractory hypotension:
Dobutamine (along with fluids)
❑ Other inotropes:
 
 
May be needed in patients with cardiogenic shock secondary to RVMI:
❑ Direct RV support
❑ Indirect RV support
❑ Biventricular support

Do's

Don'ts

References


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