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Right ventricle myocardial infarction
Background: A case report in 1974 was the first to mention right ventricle (RV) infarction as a distinct entity, noting that patients with this pathology exhibit "a unique clinical and haemodynamic syndrome". This is because the resulting weakness of the RV makes the patient's cardiac output extremely preload sensitive. They often present in shock and even if they are normotensive initially, giving GTN can precipitate a severe drop in blood pressure or even trigger cardiac arrest. These are an important group of patients to identify!
Thygesen K, Alpert J, Jaffe A, et al. Fourth universal definition of myocardial infarction. European Heart Journal 2019;40(3):237-269
The paper: This is another nugget from the 4th Universal Definition of Myocardial Infarction, published last year. It highlights the necessity of obtaining recordings from supplemental leads in certain patients. They note that an RV infarct is very rarely isolated but usually occurs as part of an inferior STEMI (Up To Date suggests 30-50% of inferior STEMIs have this complication). Supplemental leads V3R and V4R are placed on the right side of the chest, opposite the standard V3 and V4. ST elevation >0.5mm in either of these supplementary leads is considered diagnostic of RV infarction. Other ECG changes suggestive of RV infarction include ST elevation in aVR or V1, but several experts recommend deploying the supplemental leads in every case of inferior MI, because missing an RV infarct can be devastating for the patient.
The bottom line: Be aware of RV infarction as a potential complication of inferior STEMI and actively look for it by deploying supplemental leads. Don't give GTN to these patients! They need IV fluids in the first instance.
Note: Amal Mattu (Cardiology EM consultant at University of Maryland, USA and producer of the excellent ECG Weekly) suggests looking for the following triad to identify patients at risk of RV infarction...- Chest pain- Hypotension- No crackles on auscultationYou need all three because the other main differential for MI + shock is flash pulmonary oedema.
Expert commentary:"This is really great learning, and the triad is easily memorable."(Dr Robert Tan, ED Consultant)
More FOAMed on this topic:Life in the fast laneDr Smith's ECG blog (to take things to the next level)ECG weekly - not quite FOAMed but (I think) the best ECG resource around and it's pretty inexpensive
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By Barrie StevensonBackground: A case report in 1974 was the first to mention right ventricle (RV) infarction as a distinct entity, noting that patients with this pathology exhibit "a unique clinical and haemodynamic syndrome". This is because the resulting weakness of the RV makes the patient's cardiac output extremely preload sensitive. They often present in shock and even if they are normotensive initially, giving GTN can precipitate a severe drop in blood pressure or even trigger cardiac arrest. These are an important group of patients to identify!
Thygesen K, Alpert J, Jaffe A, et al. Fourth universal definition of myocardial infarction. European Heart Journal 2019;40(3):237-269
The paper: This is another nugget from the 4th Universal Definition of Myocardial Infarction, published last year. It highlights the necessity of obtaining recordings from supplemental leads in certain patients. They note that an RV infarct is very rarely isolated but usually occurs as part of an inferior STEMI (Up To Date suggests 30-50% of inferior STEMIs have this complication). Supplemental leads V3R and V4R are placed on the right side of the chest, opposite the standard V3 and V4. ST elevation >0.5mm in either of these supplementary leads is considered diagnostic of RV infarction. Other ECG changes suggestive of RV infarction include ST elevation in aVR or V1, but several experts recommend deploying the supplemental leads in every case of inferior MI, because missing an RV infarct can be devastating for the patient.
The bottom line: Be aware of RV infarction as a potential complication of inferior STEMI and actively look for it by deploying supplemental leads. Don't give GTN to these patients! They need IV fluids in the first instance.
Note: Amal Mattu (Cardiology EM consultant at University of Maryland, USA and producer of the excellent ECG Weekly) suggests looking for the following triad to identify patients at risk of RV infarction...- Chest pain- Hypotension- No crackles on auscultationYou need all three because the other main differential for MI + shock is flash pulmonary oedema.
Expert commentary:"This is really great learning, and the triad is easily memorable."(Dr Robert Tan, ED Consultant)
More FOAMed on this topic:Life in the fast laneDr Smith's ECG blog (to take things to the next level)ECG weekly - not quite FOAMed but (I think) the best ECG resource around and it's pretty inexpensive