Makindo Medical Notes

Related Subjects: |Atherosclerosis |Ischaemic heart disease |Assessing Chest Pain |ACS: general |ACS: NSTEMI |ACS: STEMI |ACS: Right Ventricular STEMI

The possibility of other etiologies such as pulmonary embolism, pulmonary hypertension, and causes of hypovolemia may cloud the clinical picture. RVMI is a specific type of heart attack that affects the right ventricle of the heart. It often occurs in conjunction with inferior wall MI as both supplied by the RCA.

About

• ST Elevation MI can involve RV +/- LV
• Associated with raised morbidity and mortality

Aetiology

• Infarction of RV usually seen alone which is rare
• More commonly as part of an inferior MI
• Occlusion of the right coronary artery

Clinical

• Chest pain +/- radiation, dyspnoea, nausea
• Hypotension, Elevated JVP, Oliguria
• Poor capillary return

ECG lead placement

Investigations

• Bloods: Elevated troponin with MI. Dimer in PE.
• ECG: Leads V4R, V5R, and V6R are particularly important. ST-segment elevation in these leads is indicative of RVMI. Inferior Leads (II, III, aVF): Often show ST-segment elevation, as RVMI commonly occurs with IWMI.
• Echo: RV changes e.g. RV wall dyskinesia/hypokinesia, paradoxical septal motion, tricuspid regurgitation, and pulmonary regurgitation

Management

• ABC and Manage as ACS: Early reperfusion with PCI or thrombolysis restores blood flow to the RCA
• Hypotension: Give fluids 500 mls over 15-20 mins and/or Inotropes.
• Need to ensure Right heart filling and watch out for pulmonary oedema
• Nitrates are generally contraindicated in RVMI because they reduce preload, which can exacerbate hypotension.
• Dobutamine may be used to improve RV contractility if hypotension persists despite adequate fluid resuscitation.

References

• Right Ventricular Myocardial Infarction
• Life in the fast lane ED site