From the Guidelines
For a 65-year-old man with difficult breathing and an RSR' pattern in leads V2-V3, immediate treatment should focus on addressing potential right ventricular outflow tract obstruction or right bundle branch block, with supplemental oxygen and aspirin being the initial steps, as recommended by the most recent guidelines 1. The patient's symptoms of difficult breathing and the RSR' pattern on the ECG suggest a potential cardiac issue, and the first priority should be to ensure adequate oxygenation and to reduce the risk of further cardiac complications.
- Initial management includes:
- Supplemental oxygen to maintain saturation above 94%
- Aspirin 325mg
- Nitroglycerin 0.4mg sublingually if blood pressure permits (systolic >90mmHg)
- An ECG should be obtained promptly to evaluate for acute coronary syndrome, as the RSR' pattern may indicate right ventricular strain 1.
- Laboratory tests including cardiac enzymes, BNP, and electrolytes should be ordered to further evaluate the patient's condition.
- If acute coronary syndrome is suspected, heparin (80 units/kg bolus followed by infusion) and additional antiplatelet therapy like clopidogrel 300-600mg should be considered, as recommended by the American Heart Association guidelines 1.
- For respiratory distress, bronchodilators such as albuterol via nebulizer may help, particularly if there's a bronchospastic component, and diuretics like furosemide 40mg IV may be beneficial if heart failure is contributing to symptoms. The approach should address both cardiac and pulmonary causes while the diagnostic workup continues to determine the underlying etiology of the RSR' pattern and respiratory distress, with a focus on reducing morbidity, mortality, and improving quality of life, as emphasized by the European Society of Cardiology guidelines 1.
From the Research
Presentation and Diagnosis
- A 65-year-old man presenting with difficult breathing and an RSR pattern in V2 V3 on an electrocardiogram (ECG) may be experiencing acute coronary syndrome (ACS) 2, 3.
- The RSR pattern, also known as a pseudo-R wave, can be a sign of myocardial infarction or ischemia 3.
- ACS is characterized by a sudden reduction in blood supply to the heart and can present with symptoms such as chest discomfort, dyspnea, or nonspecific symptoms 3.
Treatment and Management
- Aspirin is recommended for all patients with suspected ACS unless contraindicated, as it can help reduce mortality 2, 4, 5.
- Nitroglycerin can be administered to relieve angina and improve symptoms 2, 4, 5.
- Beta blockers can also be used if not contraindicated, as they can help reduce mortality and improve outcomes 2, 5.
- For patients with ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible, ideally within 120 minutes of first medical contact 2, 3, 5.
- If PCI is not available, fibrinolytic therapy can be used as an alternative, but it is typically reserved for patients without access to immediate PCI 2, 3, 5.
- For patients with non-ST-segment elevation ACS (NSTE-ACS), PCI is recommended, but fibrinolytic therapy is not typically used 2, 3.
Prehospital Care
- Prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals may be beneficial for patients with suspected ACS, although the certainty of evidence is very low 4.
- Prehospital aspirin administration has been associated with significantly lower 30-day and 1-year mortality compared to aspirin administration after arrival at the hospital 4.
- Prehospital nitroglycerin administration has also been associated with significantly lower 30-day and 1-year mortality compared to no prehospital administration 4.