What are the key aspects of right ventricular myocardial infarction (MI)?

From the Guidelines

Right ventricular myocardial infarction (RVMI) is a serious condition that requires prompt recognition and management to reduce morbidity and mortality, with key aspects including its association with inferior wall MI, presentation with hypotension, clear lung fields, and elevated jugular venous pressure, and the need for early reperfusion therapy and maintenance of RV preload. The 10 most important things to know about RVMI include:

• Its common association with inferior wall MI, occurring in about 30-50% of these cases 1
• Presentation with a triad of hypotension, clear lung fields, and elevated jugular venous pressure, often accompanied by ST-segment elevation in right-sided ECG leads, particularly V4R 1
• Diagnosis requires a high index of suspicion and right-sided ECG leads, as standard 12-lead ECGs may miss the condition 1
• Management focuses on maintaining RV preload through volume resuscitation with normal saline (500-1000 mL boluses), avoiding nitrates and diuretics which can worsen hypotension by reducing preload 1
• Inotropic support with dobutamine (2-20 mcg/kg/min) may be necessary for persistent hypotension despite fluid resuscitation 1
• Early reperfusion therapy, preferably primary PCI, is crucial for improving outcomes 1
• Patients with RVMI are particularly prone to bradyarrhythmias and high-degree AV blocks, which may require temporary pacing 1
• Mechanical complications like tricuspid regurgitation and right-to-left shunting through a patent foramen ovale can occur 1
• Despite its initially severe presentation, RVMI often has better long-term prognosis than isolated left ventricular MI, with significant recovery of right ventricular function within 3-6 months in many patients 1
• The importance of maintaining AV synchrony and avoiding vasodilator drugs such as opioids, nitrates, diuretics, and ACE-inhibitors/ARBs in the management of RVMI 1

From the Research

Key Points About Right Ventricular MI

• Right ventricular myocardial infarctions (RVMIs) often accompany inferior wall ischemia in up to one-half of cases 2.
• The clinical sequelae of RVMIs can vary from no hemodynamic compromise to severe hypotension and cardiogenic shock 2, 3.
• Diagnosis of RVMIs is based on physical examination, electrocardiography, echocardiography, and coronary angiography, with right-sided precordial leads being essential for assessment of RV involvement 2, 3, 4.
• Treatment of RVMIs involves adequate fluid administration, positive inotropic agents, and early coronary reperfusion, while avoiding diuretics and nitrates 2, 5.
• Intra-aortic balloon counterpulsation and right ventricle assist devices may be used in cases of medically refractory heart failure 2.
• Right ventricular involvement is an independent prognostic factor that increases in-hospital mortality due to a higher risk of hemodynamically compromising arrhythmias 2, 3, 4.

Important Considerations

• RVMI can occur in up to 50% of inferior myocardial infarctions, although isolated RVMI is rare 3.
• Acute RV shock has a high mortality rate, similar to left ventricular shock 3.
• Identification of RV involvement, particularly in the setting of hypotension, can help anticipate and prevent complications 3, 6.
• Reperfusion therapy, such as primary percutaneous coronary intervention, can hasten and enhance RV functional recovery 3, 6.
• Clinical signs and symptoms of RVMI, such as raised jugular venous pulse, hypotension, and tricuspid regurgitation, should be recognized and managed promptly 4, 5.