Right ventricular myocardial infarction initial care: Difference between revisions
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==Overview== | ==Overview== | ||
In addition to the [[reperfusion therapy]] for [[STEMI]], the acute treatment of [[right ventricular myocardial infarction]] is supportive. Volume expansion with normal saline is the primary supportive treatment for the hemodynamic abnormalities of a right ventricular myocardial infarction. [[Inotropic]] agents, such as intravenous [[ | In addition to the [[reperfusion therapy]] for [[STEMI]], the acute treatment of [[right ventricular myocardial infarction]] is supportive. Volume expansion with normal saline is the primary supportive treatment for the hemodynamic abnormalities of a right ventricular myocardial infarction. [[Inotropic]] agents, such as intravenous [[dopamine]], are appropriate in patients whose [[hypotension]] is not corrected after 1 L of saline infusion. B-blocker therapy with [[metoprolol]] is contraindicated due to [[bradycardia]]. Additionally, [[nitroglycerin]] is contraindicated in these patients due to risk of [[hypotension]]. | ||
== Treatment == | == Treatment == | ||
===Initial supportive therapy=== | ===Initial supportive therapy=== | ||
* Initial therapy in symptomatic patients is aimed at reversing the decreased filling and right-sided stroke volume | * Initial therapy in symptomatic patients is aimed at reversing the decreased filling and right-sided stroke volume while also improving right ventricular function. | ||
====Aggressive fluid resuscitation==== | ====Aggressive fluid resuscitation==== | ||
* Intravenous fluid, usually isotonic saline, should be given to raise the central filling pressure | * Intravenous fluid, usually isotonic saline, should be given to raise the central filling pressure. This is an attempt to maximize forward flow out of the right ventricle, which prevents 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. | * 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, | * If central hemodynamic monitoring in not available, 1 - 2 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==== | ====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 | * Systemic [[cardiac output]] is dependent upon filling of the left ventricle. In the setting of right ventricular dysfunction and decreased contractility, a 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 any maneuvers that decrease [[preload]] should be avoided. | ||
====Inotropic stimulation==== | ====Inotropic stimulation==== | ||
* When fluid resuscitation is insufficient, [[inotropic]] and [[chronotropic]] stimulation with [[dobutamine]] may increase forward flow and augment [[cardiac output]]. | * 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]]. | * [[Dobutamine]] may also act by reducing [[pulmonary vascular resistance]] and therefore right ventricular [[afterload]]. | ||
* The | * The initial dose of [[dobutamine]] is 5 µg/kg/min and it can be titrated up to 20 µg/kg/min as needed. | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Intensive care medicine]] | |||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 22:48, 12 March 2014
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Right ventricular myocardial infarction Microchapters |
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Differentiating Right ventricular myocardial infarction from other Diseases |
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Diagnosis |
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Treatment |
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Pharmacological Reperfusion |
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Mechanical Reperfusion |
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Antithrombin Therapy |
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Antiplatelet Agents |
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Other Initial Therapy |
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Right ventricular myocardial infarction initial care On the Web |
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Right ventricular myocardial infarction initial care in the news |
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Blogs on Right ventricular myocardial infarction initial care |
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Directions to Hospitals Treating Right ventricular myocardial infarction |
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Risk calculators and risk factors for Right ventricular myocardial infarction initial care |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
In addition to the reperfusion therapy for STEMI, the acute treatment of right ventricular myocardial infarction is supportive. Volume expansion with normal saline is the primary supportive treatment for the hemodynamic abnormalities of a right ventricular myocardial infarction. Inotropic agents, such as intravenous dopamine, are appropriate in patients whose hypotension is not corrected after 1 L of saline infusion. B-blocker therapy with metoprolol is contraindicated due to bradycardia. Additionally, nitroglycerin is contraindicated in these patients due to risk of hypotension.
Treatment
Initial supportive therapy
- Initial therapy in symptomatic patients is aimed at reversing the decreased filling and right-sided stroke volume while also improving right ventricular function.
Aggressive fluid resuscitation
- Intravenous fluid, usually isotonic saline, should be given to raise the central filling pressure. This is an attempt to maximize forward flow out of the right ventricle, which prevents inappropriate low left-sided filling pressures. [1] [2]
- 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, 1 - 2 liters of saline can be infused while closely following the blood pressure and urine output and examining the patient for 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, a 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 any maneuvers that decrease preload should be avoided.
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 initial dose of dobutamine is 5 µg/kg/min and it can be titrated up to 20 µg/kg/min as needed.
References
- ↑ Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631
- ↑ 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