Right ventricular myocardial infarction initial care

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Right ventricular myocardial infarction Microchapters

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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

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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 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

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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