What is the management approach for a patient presenting with right ventricular (RV) strain on electrocardiogram (ECG)?

Management of Right Ventricular Strain on ECG

When RV strain is identified on ECG, immediately assess for pulmonary embolism, acute coronary syndrome with RV involvement (especially inferior STEMI), and arrhythmogenic right ventricular cardiomyopathy, as these conditions require urgent intervention and carry significant mortality risk. 1

Immediate Diagnostic Workup

ECG Assessment

• Identify specific RV strain patterns: Look for S1Q3T3, complete or incomplete RBBB, T-wave inversions in V1-V4, or any combination of these findings 2
• In inferior STEMI, immediately obtain right precordial leads (V3R and V4R) to detect RV involvement, defined as ST elevation ≥0.5 mm (≥1 mm in men <30 years) 3
• Repeat ECG recordings to detect dynamic changes that distinguish acute pathology from chronic conditions 4

Determine the Underlying Etiology

For suspected pulmonary embolism:

• Order CT pulmonary angiography immediately, which has 88% sensitivity for RV strain (defined as RV:LV ratio ≥0.9 or interventricular septal bowing) 5
• Obtain transthoracic echocardiography for additional prognostic value, as RV strain on both CT and TTE predicts 30% risk of severe clinical deterioration versus only 3-4% when absent on both modalities 5
• Patients with syncope AND RV strain on multimodality assessment have 50% likelihood of requiring advanced therapies 6

For suspected RV infarction (inferior STEMI with RV involvement):

• The clinical triad of hypotension, clear lung fields, and elevated jugular venous pressure is specific but insensitive 3
• Perform echocardiography to confirm RV dysfunction and assess degree of involvement 3
• Proceed immediately to primary PCI as the preferred reperfusion strategy, which may result in rapid hemodynamic improvement 3

For suspected arrhythmogenic cardiomyopathy:

• Obtain comprehensive echocardiography assessing: RV fractional area change (<40% abnormal), TAPSE (<17mm abnormal), RV longitudinal strain of lateral free wall (worse than -23% abnormal), and 3D RV-EF (<40% abnormal) 1
• Consider cardiac MRI when echocardiography does not provide accurate assessment of RV function and structural changes 1
• Electrophysiological study may be considered for differential diagnosis of ARVC versus benign RVOT tachycardia 1

Critical Management Based on Etiology

RV Infarction Management (Fundamentally Different from LV-Predominant STEMI)

Hemodynamic support:

• Maintain RV preload through rapid IV fluid loading as the cornerstone of management 3
• Strictly avoid all vasodilators including opioids, nitrates, diuretics, and ACE-inhibitors, as these can cause catastrophic hypotension 3

Arrhythmia management:

• Promptly correct atrial fibrillation as atrial contribution to RV filling is critically important 3
• Institute dual chamber pacing immediately if heart block develops, as AV synchrony is essential for maintaining adequate RV filling and cardiac output 3

Reperfusion:

• Primary PCI is preferred and should be performed as soon as possible 3
• Fibrinolytic therapy is appropriate in hypotensive patients if PCI is not immediately available 3

Pulmonary Embolism with RV Strain

• Echocardiographic findings suggesting PE include: increased RV:LV size ratio, abnormal septal motion, McConnell's sign, tricuspid regurgitation, elevated pulmonary artery systolic pressure, decreased TAPSE, and decreased RV free wall strain 7
• Patients with RV strain on multimodality assessment (CT, TTE, and ECG) have significantly higher rates of clinical deterioration and require closer monitoring 5, 6

Arrhythmogenic Cardiomyopathy

Medical therapy:

• Beta blockers and/or calcium channel blockers (and/or IC agents in RVOT VT) are useful in patients with symptomatic VT arising from the RV 1
• Patients who experience syncope while on beta blockers are considered higher risk and often recommended for ICD implantation 1

Interventional therapy:

• Catheter ablation is useful in patients with structurally normal hearts with symptomatic, drug-refractory VT arising from the RV 1
• ICD implantation can be effective for termination of sustained VT in patients with normal or near-normal ventricular function receiving chronic optimal medical therapy 1

Common Pitfalls and How to Avoid Them

• Failing to record right-sided leads in inferior STEMI: Always obtain V3R and V4R in any inferior MI, as 40-50% have RV involvement 3
• Treating RV infarction like standard LV infarction: Giving nitrates and diuretics can cause catastrophic hypotension; instead give IV fluids aggressively 3
• Assuming benign early repolarization or RBBB excludes STEMI: Proceed with emergency coronary angiography when clinical suspicion of myocardial ischemia exists despite these conditions 4
• Relying on single imaging modality for PE: TTE confers additional positive prognostic value compared to CT alone in predicting post-PE clinical deterioration 5
• Missing ARVC in young patients with RVOT VT: The ECG in sinus rhythm helps distinguish benign RVOT tachycardia from the more serious condition of RV dysplasia where the ECG is more often abnormal 1

Follow-up Considerations

• Patients with arrhythmogenic cardiomyopathy should be followed every 1-2 years with echocardiography-Doppler assessment of RV systolic pressure and function 1
• After surgical relief of RVOT obstruction, patients require ongoing surveillance with measurement of gradients across the RVOT 1