Sandbox:Mitra
❑ Order ECG ❑ Order serial cardiac biomarkers (troponins) and CK MB ❑ Perform a bedside echocardiography (if available) | |||||||||||||||||||||||||||||||||
Does the patient fulfill the criteria of myocardial infarction? ❑ Rise and/or fall of cardiac biomarker, preferably troponin, with at least one of the measurements >99th percentile of the upper limit of normal
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Yes | No | ||||||||||||||||||||||||||||||||
Rule out the following life-threatening conditions | |||||||||||||||||||||||||||||||||
Aortic dissection | Pulmonary embolism | Tension pneumothorax | Esophageal rupture | ||||||||||||||||||||||||||||||
Look for supportive symptoms and signs: ❑ Sudden onset of chest pain radiating to the back or interscapular pain
| Look for supportive symptoms and signs: ❑ Pleuritic chest pain
| Look for supportive symptoms and signs: ❑ Sudden onset of shortness of breath | Look for supportive symptoms and signs: ❑ Vomiting | ||||||||||||||||||||||||||||||
Click here for the detailed management | Click here for the detailed management | Click here for the detailed management | Click here for the detailed management | ||||||||||||||||||||||||||||||
Do's
- Right ventricular myocardial infarction (RVMI) should be ruled out in all patients presenting with acute inferior wall myocardial infarction, in particular in patients with hypotension.
- In patients presenting with chest pain and clinical findings of hypotension, elevated JVP and clear lung fields, consider the differential diagnoses of RVMI. These include:
- Systemic or pulmonary vasodilators may be considered in selected patients to reduce RV afterload, thereby improving cardiac output.
- In patients with severe tricuspid regurgitation due to RVMI, replacement of tricuspid valve or repair of the valve with annuloplasty rings may be considered.
- In patients with RVMI who have unexplained hypoxemia despite administration of 100% oxygen, right-to-left shunting -through a patent foramen ovale or atrial septal defect-, caused by the disproportionate elevation in right-sided filling pressures compared to the normal or slightly increased left-sided filling pressures should be considered.
- Patients with extensive necrosis due to RVMI may be at higher risk of right ventricular perforation during interventional procedures. Right ventricular catheterization or pacemaker insertion should be performed with great care in these patients.
Don'ts
- In patients with RVMI, avoid preload-reducing agents such as nitrates, diuretics, morphine, beta-blockers, and calcium channel blockers.