eMedicine Specialties > Cardiology > Coronary Artery Disease

Right Ventricular Infarction: Differential Diagnoses & Workup

Author: Claudia Dima, MD, Cardiology Fellow, Banner Good Samaritan Medical Center
Coauthor(s): Ashish Pershad, MD, Consulting Staff, Heart and Vascular Center of Arizona; David L Coven, MD, PhD, Assistant Professor of Medicine, Columbia University College of Physicians and Surgeons; Attending Physician in Interventional Cardiology, St Luke's-Roosevelt Hospital Center; Kenneth Desser, MD, Director of Cardiology Fellowship, Clinical Professor, Department of Medicine, University of Arizona College of Medicine
Contributor Information and Disclosures

Updated: Oct 9, 2008

Differential Diagnoses

Cardiomyopathy, Hypertrophic
Pulmonary Embolism
Cardiomyopathy, Restrictive
Pulmonary Hypertension, Primary
Cor Pulmonale
Pulmonary Hypertension, Secondary
Endomyocardial Fibrosis
Tricuspid Regurgitation
Pericarditis, Acute
Pericarditis, Constrictive
Pneumothorax

Workup

Imaging Studies

  • In the appropriate clinical setting, a diagnosis of right ventricular infarction can be made using noninvasive techniques, or the patient may require right ventricular catheterization and hemodynamic monitoring.
  • Echocardiography is useful as a modality to rule out pericardial disease and tamponade, which are the major differential diagnoses in the setting of a right ventricular infarction.
    • Right ventricular dilatation, abnormal right ventricular wall motion, paradoxical motion of the interventricular septum, and tricuspid regurgitation are echocardiographic features of right ventricular infarction.
    • As might be expected, tricuspid regurgitation in this setting is detected more frequently by ultrasound than by auscultation of a tricuspid regurgitation murmur.
    • Echocardiogram can detect shunting through a patent foramen ovale.
    • Echocardiogram has an 82% sensitivity and 93% specificity in detecting right ventricular infarction when right ventricular scintigraphy is used as the comparative standard.24
    • In the vast majority of patients with right ventricular infarction, the wall motion abnormalities initially manifest on echocardiography reverse within 3 months.25
    • The use of tissue Doppler in echocardiography has also increased, providing another means to detect right ventricular infarction. A decrease in the systolic velocity at the tricuspid annulus not only allows for diagnosis of right ventricular infarction but also suggests worse mortality outcome.26
    • Another echocardiographically obtained value that can aid in diagnosis of right ventricular infarction is the myocardial performance index (MPI). MPI is derived from the sum of the isovolumic relaxation and contraction time divided by the ejection fraction. An abnormally elevated MPI of >0.30 suggests the presence of a right ventricular infarction.27
  • Gated equilibrium radionuclide angiography and technetium 99m pyrophosphate scintigraphy are useful in diagnosing right ventricular infarction noninvasively.28 In the case of radionuclide angiography, the right ventricle is demonstrated to be enlarged and poorly contractile, with a reduced ejection fraction. When technetium 99m pyrophosphate is employed, the right ventricular free wall is "hot," indicating significant infarction.

Other Tests

  • Electrocardiography
    • All patients with inferior wall myocardial infarction should have a right-sided ECG. ST-segment elevation in lead V4R is the single most powerful predictor of right ventricular involvement, identifying a high-risk subset of patients in the setting of inferior wall myocardial infarction.29 The ST-segment elevation is transient, disappearing in less than 10 hours following its onset in half of patients. The following table demonstrates the sensitivity and specificity of more than 1 mm of ST-segment elevation in V1, V3 R, and V4 R.30 Sensitivity and Specificity of more than 1 mm of ST-Segment Elevation in V1, V3 R, and V4 R

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      Table
      LeadsSensitivity (%)Specificity (%)
      V1 2892
      V3 R6997
      V4 R9395
      LeadsSensitivity (%)Specificity (%)
      V1 2892
      V3 R6997
      V4 R9395
    • Isolated right ventricular infarct is extremely rare and may be interpreted erroneously as left ventricular anteroseptal infarction on ECG because of ST-segment elevation in leads V1 -V4.31,32 Some have suggested that the differential diagnosis between the 2 abnormalities can be distinguished by using vectorial analysis. The mean ST-segment vector in right ventricular infarction usually is directed anteriorly and to the right (>100°).
    • In an anteroseptal left ventricular infarct, the mean ST-segment vector is oriented leftward between -30° and -90° thus, analysis of the frontal and horizontal plane axis of the mean ST-segment vector can distinguish electrocardiographically between myocardial infarction at these 2 sites.33 There has also been some discussion about right ventricular infarctions giving rise to an epsilon wave. However, because of the low voltage of this wave, low sensitivity, and low specificity, this electrocardiographic feature is of little value in daily practice.34
  • Hemodynamic monitoring
    • Disproportionate elevation of right-sided filling pressures when compared with left-sided hemodynamics represents the hallmark of right ventricular infarction.
    • Accepted hemodynamic criteria for right ventricular infarction include right atrial pressure greater than 10 mm Hg, right atrial–to–pulmonary capillary wedge pressure ratio greater than 0.8, or right atrial pressure within 5 mm Hg of the pulmonary capillary wedge pressure. These values may manifest only after volume loading.35
    • In the setting of right ventricular infarction, pulmonary capillary wedge pressure may be misleading and not accurately reflect left ventricular end-diastolic volume but rather impaired left ventricular filling due to bowing of the interventricular septum into the left ventricle.36
    • Other interesting hemodynamic features of right ventricular infarction include the following:
      • Prominent y descent of the right atrial pressure
      • Increase in venous or right atrial pressure with inspiration (ie, Kussmaul sign)
      • Exaggeration of the normal inspiratory decline in systemic arterial pressure (ie, pulsus paradoxus)
      • Elevation of right ventricular filling pressure with early diastolic dip and plateau
  • Some of these hemodynamic derangements superficially resemble those of restrictive or constrictive physiology.

More on Right Ventricular Infarction

Overview: Right Ventricular Infarction
Differential Diagnoses & Workup: Right Ventricular Infarction
Treatment & Medication: Right Ventricular Infarction
Follow-up: Right Ventricular Infarction
References
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References

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Further Reading

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Keywords

right ventricle infarction, RVI, myocardial infarction, MI, right ventricular dysfunction, right coronary artery occlusion

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Contributor Information and Disclosures

Author

Claudia Dima, MD, Cardiology Fellow, Banner Good Samaritan Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Ashish Pershad, MD, Consulting Staff, Heart and Vascular Center of Arizona
Ashish Pershad, MD is a member of the following medical societies: American College of Cardiology
Disclosure: Nothing to disclose.

David L Coven, MD, PhD, Assistant Professor of Medicine, Columbia University College of Physicians and Surgeons; Attending Physician in Interventional Cardiology, St Luke's-Roosevelt Hospital Center
David L Coven, MD, PhD is a member of the following medical societies: American College of Physicians, American Medical Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Kenneth Desser, MD, Director of Cardiology Fellowship, Clinical Professor, Department of Medicine, University of Arizona College of Medicine
Disclosure: Nothing to disclose.

Medical Editor

George A Stouffer III, MD, Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center
George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marschall S Runge, MD, PhD, Charles and Anne Sanders Distinguished Professor of Medicine, Chairman of Medicine, Vice Dean for Clinical Affairs, Chairman, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine
Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association
Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD, Assistant Professor of Medicine, Director of Coronary Care Unit, University of North Carolina at Chapel Hill School of Medicine
Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Up to Date Royalty Review panel membership; pfizer Honoraria Speaking and teaching

 
 
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