Sandbox:Mitra3

All patients with acute inferior wall myocardial infarction (ST elevation in leads II, III, aVF)

Obtain right-sided precordial leads

>= 1mm ST elevation in lead V4R

Highly suggestive of RVMI

Physical examination

Echocardiography

Coronary Angiography

Hemodynamic study

❑ Classic triad of: ❑ Hypotension ❑ Elevated JVP ❑ Clear Lungs ❑ Kussmaul sign ❑ Pulsus paradoxus ❑ Tricuspid regurgitation murmur ❑ Atrioventrcicular dissociation ❑ Vagal symptoms: Bradycardia ❑ Nausea ❑ Vomiting ❑ Diaphoresis ❑ Pallor

❑ RV dilatation ❑ Depressed RV systolic function ❑ RV wall akinesia or dyskinesia ❑ RA enlargement ❑ Elevated pulmonary pressures ❑ Pulmonary regurgitation ❑ Tricuspid regurgitation ❑ Increased right atrial pressure

Gold standard diagnostic modality ❑ In the majority of RVMI: ❑ The culprit artery: Proximal RCA ❑ Occasionally: ❑ The culprit artery: Left circumflex or left anterior descending artery

❑ Hemodynamically significant RVMI: ❑ Increased RAP>10 mmHg ❑ RAP to PCWP ratio >0.8 (normal<0.6) ❑ RAP within 5 mmHg of the PCWP ❑ Reduced cardiac index ❑ Disproportionate elevation of right-sided filling pressures: Hallmark of RVMI ❑ In concomitant LV dysfunction: ❑ RAP to PCWP ratio can change ❑ Additional hemodynamic changes: ❑ Prominent Y-descend of the RAP ❑ Drop of the systemic arterial pressure >10 mmHg with inspiration ❑ "Dip and plateau" morphology and equalization of the diastolic filling pressures