What is the appropriate management for a patient with suspected Right Ventricular Infarction?

Management of Right Ventricular Infarction

Aggressive intravenous fluid resuscitation with normal saline is the cornerstone of initial management for right ventricular infarction, while strictly avoiding diuretics and nitrates which can precipitate catastrophic hypotension. 1

Diagnosis and Recognition

Suspect RV infarction in any patient presenting with inferior MI (ST elevation in leads II, III, aVF) who exhibits the clinical triad of hypotension, elevated jugular venous pressure, and clear lung fields. 1, 2

Diagnostic Steps:

• Immediately obtain right-sided precordial ECG leads (V3R-V4R) in all patients with inferior MI—ST elevation ≥0.1 mV (1 mm) in V4R is highly specific for RV infarction 1, 3
• Look for increased jugular venous pressure during inspiration (Kussmaul's sign) as a key clinical finding 1
• Perform echocardiography to confirm RV dilatation and hypokinesis, which helps clarify diagnosis when clinical picture is uncertain 1
• Consider pulmonary artery catheter insertion for hemodynamic monitoring—this reveals elevated right-sided filling pressures disproportionate to left-sided pressures 1, 2

Initial Hemodynamic Management

Volume Resuscitation (First-Line Therapy):

Administer normal saline aggressively: give 500 mL bolus initially, followed by 500 mL/hour infusion to maintain elevated right ventricular preload necessary for adequate cardiac output. 1

• Monitor response using clinical variables: systemic blood pressure, peripheral perfusion, urine output, and absence of ventricular gallop sounds 1
• Target pulmonary artery wedge pressure of 14-18 mm Hg when hemodynamic monitoring is available 1
• Continue fluid administration until clinical improvement occurs or signs of left ventricular volume overload develop 1

Critical Medications to AVOID:

Never administer diuretics or nitrates in suspected RV infarction—these agents cause severe hypotension by reducing the elevated right-sided filling pressure required to maintain cardiac output. 1

• Nitrates are absolutely contraindicated in RV infarction regardless of chest pain 1
• This represents a fundamental difference from left ventricular MI management where nitrates are routinely used 1

Reperfusion Therapy

Initiate immediate reperfusion with primary PCI or fibrinolytic therapy—early reperfusion is critical as it reduces mortality and improves RV functional recovery. 2, 3, 4

• Primary PCI is preferred if achievable within 120 minutes of diagnosis 5
• If PCI unavailable, administer fibrinolytic therapy immediately (within 10 minutes of STEMI diagnosis) 5
• Early reperfusion has been reported to reduce mortality from >85% to approximately 60% in shock patients 1

Management of Refractory Hypotension

If hypotension persists despite adequate fluid resuscitation, escalate to inotropic support with dobutamine as the preferred agent. 1, 2, 6

Escalation Algorithm:

1. First: Complete fluid challenge (typically 1-2 liters normal saline) 1
2. Second: Add dobutamine for inotropic support of the failing right ventricle 1, 2
3. Third: If shock persists despite dopamine 2-15 µg/kg/min, institute intra-aortic balloon counterpulsation for potentially reversible conditions 1
4. Fourth: If IABP unavailable, add norepinephrine to maintain systolic pressure 80-100 mm Hg and arrange emergency transfer 1

Rhythm Management

Maintain atrioventricular synchrony and appropriate heart rate—bradycardia and AV block are common complications that severely compromise cardiac output in RV infarction. 2, 3, 7

• Treat symptomatic bradycardia aggressively with atropine or temporary pacing 3
• Restore sinus rhythm promptly if atrial fibrillation develops, as atrial contraction contributes significantly to RV filling 3, 7
• AV sequential pacing is preferred over ventricular pacing alone to preserve atrial contribution 2, 7

Hemodynamic Monitoring

Insert pulmonary artery catheter for hemodynamic monitoring when diagnosis is unclear or patient fails to respond to initial fluid resuscitation. 1

• This allows precise assessment of intravascular volume status and optimization of fluid administration 1
• Standard pressure criteria for volume assessment do not apply in the presence of ventricular dysfunction 1
• Hemodynamic monitoring guides the transition from volume loading to inotropic support 1

Common Pitfalls to Avoid

• Never reflexively administer diuretics for elevated JVP in the setting of inferior MI—always obtain right-sided ECG leads first 1
• Never give nitrates for chest pain without first excluding RV infarction in inferior MI patients—this can cause cardiovascular collapse 1
• Never assume clear lung fields rule out significant MI—this is the classic presentation of RV infarction 1, 2
• Never delay reperfusion therapy while optimizing hemodynamics—early revascularization is the definitive treatment 2, 4, 7

Prognosis and Recovery

Most patients with RV infarction experience complete recovery of right ventricular function over weeks to months, suggesting reversible "stunning" rather than permanent necrosis. 2, 6

• Despite good long-term recovery potential, in-hospital morbidity and mortality remain high (30-50% of inferior MIs involve RV) 2, 4
• Hemodynamic abnormalities typically resolve as RV function recovers 2, 6
• Early recognition and appropriate management significantly improve outcomes 4, 7