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Revision as of 18:35, 5 August 2020 by Mitra Chitsazan (talk | contribs)
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All patients with acute inferior wall myocardial infarction (ST elevation in leads II, III, aVF)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain right-sided precordial leads
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
>= 1mm ST elevation in lead V4R
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly suggestive of RVMI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
 
Echocardiography
 
Coronary Angiography
 
Hemodynamic study
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Classic triad of: • Hypotension
• Elevated JVP
• Clear Lungs
❑ Kussmaul sign ❑ Pulsus paradoxus ❑ Tricuspid regurgitation murmur ❑ Atrioventrcicular dissociation ❑ Vagal symptoms: • Bradycardia • Nausea • Vomiting • Diaphoresis

• Pallor
 

❑ RV dilatation ❑ Depressed RV systolic function ❑ RV wall akinesia or dyskinesia ❑ RA enlargement ❑ Elevated pulmonary pressures ❑ Pulmonary regurgitation ❑ Tricuspid regurgitation

❑ Increased right atrial pressure
 
Gold standard diagnostic modality

❑ In the majority of RVMI: • The culprit artery: Proximal RCA
❑ Occasionally:

• The culprit artery: Left circumflex or left anterior descending artery
 

❑ Hemodynamically significant RVMI: • Increased RAP>10 mmHg • RAP to PCWP ratio >0.8 (normal<0.6) • RAP within 5 mmHg of the PCWP • Reduced cardiac index • Disproportionate elevation of right-sided filling pressures: Hallmark of RVMI ❑ In concomitant LV dysfunction: • RAP to PCWP ratio can change ❑ Additional hemodynamic changes: •Prominent Y-descend of the RAP •Drop of the systemic arterial pressure >10 mmHg with inspiration

• "Dip and plateau" morphology and equalization of the diastolic filling pressures