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* 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]].
* 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|Pacing====
===Reperfusion therapy===
* [[Thrombolytics]]
* [[Primary PCI]]
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 01:37, 12 September 2012

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 initial care On the Web

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US National Guidelines Clearinghouse

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Right ventricular myocardial infarction initial care in the news

Blogs on Right ventricular myocardial infarction initial care

Directions to Hospitals Treating Right ventricular myocardial infarction

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 dobutamine, is 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 and at improving right ventricular function.

Aggressive fluid resuscitation

  • 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 [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, one to two 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, 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

Transvenous pacing|Pacing

References

  1. Kinch, JW, Ryan, TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211. PMID 8139631
  2. 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

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