Right ventricular myocardial infarction resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Consider right ventricular MI in case of: ❑ Hypotension ❑ Elevated jugular venous pressure ❑ Clear lung fields ❑ ECG changes suggestive of an inferior MI ❑ ST elevation in leads II, III and aVF



Order a right sided ECG in all patients with ST elevation in leads II, III and aVF ❑ Clearly label the ECG as right sided ❑ ST-segment elevation of >1 mm in lead V4R suggests a right ventricular MI



❑ Do not delay the decision and initiation of PCI vs fibrinolytic therapy ❑ Do not administer: ❑ Beta blockers ❑ Nitrates ❑ Diuretics ❑ Increase the right ventricle load by volume expansion with normal saline preferably with invasive monitoring ❑ If central hemodynamic monitoring is available, administer normal saline (40 ml/min, up to a total of 2 L, intravenously) until there is an increase in the pulmonary capillary wedge pressure to approximately 15 mmHg ^[1] ❑ If central hemodynamic monitoring in not available, administer normal saline with a close monitoring of the blood pressure



If hypotension is not corrected with 1-2 L normal saline: ❑ Administer inotropic agents ❑ Initiate hemodynamic monitoring with a pulmonary catheter if possible