eMedicine Specialties > Cardiology > Coronary Artery Disease

Right Ventricular Infarction: Treatment & Medication

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

Treatment

Medical Care

Right ventricular infarction should always be considered in any patient who has inferior wall myocardial infarction and associated hypotension, especially in the absence of rales.

RV failure may limit filling via a decrease in CO, ventricular interdependence, or both. Treatment of patients with RV dysfunction and shock has traditionally focused on ensuring adequate right-sided filling pressures to maintain CO and adequate LV preload; however, patients with cardiogenic shock due to RV dysfunction have very high RV end-diastolic pressure, often greater than 20 mm Hg. This elevation of RV end-diastolic pressure may result in shifting of the interventricular septum toward the LV cavity, which raises left atrial pressure but impairs LV filling due to the mechanical effect of the septum bowing into the LV. This alteration in geometry also impairs LV systolic function. Therefore, the common practice of aggressive fluid resuscitation for RV dysfunction in shock may be misguided. Excess volume loading in patients with RV infarction may also cause or contribute to cardiogenic shock.

Inotropic therapy is indicated for RV failure when cardiogenic shock persists after RV end-diastolic pressure has been optimized.37 Inotropes should be used until more data is available. RV end-diastolic pressure of 10-15 mm Hg has been associated with higher output than lower or higher pressures, but marked variability exists in optimal values. 
 
If hypotension persists, consider hemodynamic monitoring with a pulmonary artery catheter, keeping in mind the following admonitions concerning right ventricular perforation. Patients with extensive right ventricular necrosis are at risk for right ventricular catheter–related perforation, and passage of a floating balloon catheter or pacemaker must always be performed with great care in such a setting.
 
Concomitant left ventricular dysfunction may necessitate use of an intraaortic balloon pump and/or nitroprusside infusion for afterload reduction.
 
Because of the critical roles of atrioventricular synchrony and atrial transport in maintaining cardiac output, atrioventricular sequential pacing is the modality of choice when a pacemaker is required.38
 
Achieving early reperfusion: Current available evidence indicates that patients presenting within 6 hours of onset of inferior wall myocardial infarction with right ventricular involvement diagnosed by ECG or other noninvasive criteria have a definite early survival benefit from thrombolytic therapy or coronary angioplasty.39,40 Scant data exist regarding improvement in patients who present later than 12 hours after onset, and these patients most likely would do well with a conservative management strategy, considering the often spontaneous resolution of right ventricular dysfunction.41
 
Recently, the use of inhaled nitric oxide has been of interest to treat patients with RV infarctions complicated by cardiogenic shock. The principle behind this experimental treatment is that by specifically decreasing pulmonary vascular resistance without compromising systemic vascular resistance, the filling of the left ventricle can be improved with a resultant improvement of systemic cardiac output. Utilization of inhaled nitric oxide in this setting has been associated with rapid improvement of hemodynamics.42

Surgical Care

Severe tricuspid regurgitation in the setting of acute right ventricular infarction can be managed with either valve replacement or repair with angioplasty rings, because the incompetent valve may serve as a mechanical impediment to maintenance of adequate cardiac output. Finally, should a patient develop arterial hypoxemia secondary to right-to-left shunting at the atrial level, then an atrial septal defect–occluding device should be considered immediately. However, if for any reason, a delay occurs in placement of the occluding device, inhaled nitric oxide can decrease the right-to-left shunting and increase systemic oxygenation.42 Pericardiectomy has been used in extreme cases.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Cardiovascular agents

Dobutamine is an inotropic agent used to improve right ventricular contractility and maintain cardiac output. Sodium nitroprusside reduces afterload.


Dobutamine (Dobutrex)

Produces vasodilation and increases inotropic state. At higher dosages, may cause increased heart rate, exacerbating myocardial ischemia.

Adult

0.5 mcg/kg/min IV initial; titrate until desired effect attained

Pediatric

Administer as in adults

Beta-adrenergic blockers antagonize effects; general anesthetics may increase toxicity

Documented hypersensitivity; idiopathic hypertrophic subaortic stenosis; atrial fibrillation or flutter

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution following MI; hypovolemic state should be corrected before using


Nitroprusside (Nitropress)

Produces vasodilation and increases inotropic activity of heart. At higher doses, may exacerbate myocardial ischemia by increasing heart rate. Infusion rates >10 mcg/kg/min may lead to cyanide toxicity.

Adult

0.3-0.5 mcg/kg/min IV initial infusion; use 0.5 mcg/kg/min increments and titrate to desired effect; average dose is 1-6 mcg/kg/min

Pediatric

Administer as in adults

Coadministration with other hypotensive agents may have additive effects

Documented hypersensitivity; subaortic stenosis; idiopathic hypertrophic subaortic stenosis; decreased cerebral perfusion; arteriovenous shunt or coarctation of aorta (eg, compensatory hypertension); atrial fibrillation or flutter

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in increased intracranial pressure, hepatic failure, severe renal impairment, and hypothyroidism; in renal or hepatic insufficiency, nitroprusside levels may increase and can cause cyanide toxicity; sodium nitroprusside has ability to lower blood pressure and should be used only in patients with mean arterial pressures >70 mm Hg

Tissue plasminogen activators

These agents bind to fibrin and convert plasminogen to plasmin, which in turn initiates local fibrinolysis with limited systemic proteolysis.


Alteplase (Activase)

Tissue plasminogen activator (t-PA) used in management of acute myocardial infarction, acute ischemic stroke, and pulmonary embolism. May administer heparin or aspirin with and after alteplase infusions to reduce risk of rethrombosis. Safety and efficacy of concomitant administration of heparin or aspirin during first 24 h after symptom onset have not been investigated.

Adult

0.9 mg/kg (not to exceed 90 mg) IV infusion over 60 min with 10% of total dose administered as initial IV bolus over 1 min

Pediatric

Not established

Anticoagulants and antiplatelets may increase risk of bleeding; heparin with and after alteplase infusions reduces risk of rethrombosis—either heparin or alteplase may cause bleeding complications

Documented hypersensitivity; active internal bleeding; cerebrovascular accident or stroke within last 2 mo; intracranial or intraspinal surgery or trauma; intracranial hemorrhage on pretreatment evaluation; suspicion of subarachnoid hemorrhage; intracranial neoplasm; arteriovenous malformation or aneurysm; bleeding diathesis; severe uncontrolled hypertension

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor for bleeding, especially at arterial puncture sites, with coadministration of vitamin K antagonists; control and monitor blood pressure frequently during and following alteplase administration (when managing acute ischemic stroke); do not use >0.9 mg/kg to manage acute ischemic stroke; doses >0.9 mg/kg may cause ICH

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
[ CLOSE WINDOW ]

References

  1. Chockalingam A, Gnanavelu G, Subramaniam T, Dorairajan S, Chockalingam V. Right ventricular myocardial infarction: presentation and acute outcomes. Angiology. Jul-Aug 2005;56(4):371-6. [Medline].

  2. Forman MB, Goodin J, Phelan B. Electrocardiographic changes associated with isolated right ventricular infarction. J Am Coll Cardiol. Sep 1984;4(3):640-3. [Medline].

  3. Garty I, Barzilay J, Bloch L. The diagnosis and early complications of right ventricular infarction. Eur J Nucl Med. 1984;9(10):453-60. [Medline].

  4. Giannitsis E, Potratz J, Wiegand U. Impact of early accelerated dose tissue plasminogen activator on in- hospital patency of the infarcted vessel in patients with acute right ventricular infarction. Heart. Jun 1997;77(6):512-6. [Medline].

  5. Haupt HM, Hutchins GM, Moore GW. Right ventricular infarction: role of the moderator band artery in determining infarct size. Circulation. Jun 1983;67(6):1268-72. [Medline].

  6. Hirsowitz GS, Lakier JB, Goldstein S. Right ventricular function evaluated by radionuclide angiography in acute myocardial infarction. Am Heart J. Oct 1984;108(4 Pt 1):949-54. [Medline].

  7. Hurst JW. Comments about the electrocardiographic signs of right ventricular infarction. Clin Cardiol. Apr 1998;21(4):289-91. [Medline].

  8. Iqbal MZ, Liebson PR. Counterpulsation and dobutamine. Their use in treatment of cardiogenic shock due to right ventricular infarct. Arch Intern Med. Feb 1981;141(2):247-9. [Medline].

  9. Kinn JW, Ajluni SC, Samyn JG. Rapid hemodynamic improvement after reperfusion during right ventricular infarction. J Am Coll Cardiol. Nov 1 1995;26(5):1230-4. [Medline].

  10. Andersen HR, Nielsen D, Falk E, et al. Right ventricular infarction: larger enzyme release with posterior than with anterior involvement. Int J Cardiol. Mar 1989;22(3):347-55. [Medline].

  11. Andersen HR, Falk E, Nielsen D. Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am Coll Cardiol. Dec 1987;10(6):1223-32. [Medline].

  12. Andersen HR, Nielsen D, Lund O. Prognostic significance of right ventricular infarction diagnosed by ST elevation in right chest leads V3R to V7R. Int J Cardiol. Jun 1989;23(3):349-56. [Medline].

  13. Bates ER. Revisiting reperfusion therapy in inferior myocardial infarction. J Am Coll Cardiol. Aug 1997;30(2):334-42. [Medline].

  14. Birnbaum Y, Wagner GS, Barbash GI. Correlation of angiographic findings and right (V1 to V3) versus left (V4 to V6) precordial ST-segment depression in inferior wall acute myocardial infarction. Am J Cardiol. Jan 15 1999;83(2):143-8. [Medline].

  15. Braat SH, Brugada P, den Dulk K. Value of lead V4R for recognition of the infarct coronary artery in acute inferior myocardial infarction. Am J Cardiol. Jun 1 1984;53(11):1538-41. [Medline].

  16. Braat SH, Brugada P, de Zwaan C. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J. Apr 1983;49(4):368-72. [Medline].

  17. Elkayam U, Halprin SL, Frishman W. Echocardiographic findings in cardiogenic shock due to right ventricular myocardial infarction. Cathet Cardiovasc Diagn. 1979;5(3):289-94. [Medline].

  18. Lisbona R, Sniderman A, Derbekyan V. Phase and amplitude imaging in the diagnosis of acute right ventricular damage in inferior infarction. Clin Nucl Med. Nov 1983;8(11):517-20. [Medline].

  19. Martin W, Tweddel A, McGhie I. The evaluation of right ventricular function in acute myocardial infarction by xenon-133. Nucl Med Commun. Jan 1989;10(1):35-43. [Medline].

  20. Mittal SR. Isolated right ventricular infarction. Int J Cardiol. Aug 1994;46(1):53-60. [Medline].

  21. Nader DA, Ceretto WJ, Vieweg WV. Atrial pacing in the management of right ventricular infarction. South Med J. Mar 1981;74(3):362-3. [Medline].

  22. Pfisterer M, Emmenegger H, Muller-Brand J. Prevalence and extent of right ventricular dysfunction after myocardial infarction--relation to location and extent of infarction and left ventricular function. Int J Cardiol. Sep 1990;28(3):325-32. [Medline].

  23. Mavric Z, Zaputovic L, Matana A. Prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and without right ventricular involvement. Am Heart J. Apr 1990;119(4):823-8. [Medline].

  24. Singhal AM, Ilangovan S, Mehta S. Isolated right ventricular infarction followed by posterior left ventricular infarction after a few days. Acta Cardiol. 1984;39(4):307-12. [Medline].

  25. Strauss HD, Sobel BE, Roberts R. The influence of occult right ventricular infarction on enzymatically estimated infarct size, hemodynamics and prognosis. Circulation. Sep 1980;62(3):503-8. [Medline].

  26. Dokainish H, Abbey H, Gin K, Ramanathan K, Lee PK, Jue J. Usefulness of tissue Doppler imaging in the diagnosis and prognosis of acute right ventricular infarction with inferior wall acute left ventricular infarction. Am J Cardiol. May 1 2005;95(9):1039-42. [Medline].

  27. Chockalingam A, Gnanavelu G, Alagesan R, Subramaniam T. Myocardial performance index in evaluation of acute right ventricular myocardial infarction. Echocardiography. Aug 2004;21(6):487-94. [Medline].

  28. Sugimoto T, Ogawa K, Asada T. Surgical treatment of ventricular septal perforation with right ventricular infarction. J Cardiovasc Surg (Torino). Feb 1996;37(1):71-4. [Medline].

  29. Robalino BD, Petrella RW, Jubran FY. Atrial natriuretic factor in patients with right ventricular infarction. J Am Coll Cardiol. Mar 1 1990;15(3):546-53. [Medline].

  30. Roth A, Miller HI, Kaluski E. Early thrombolytic therapy does not enhance the recovery of the right ventricle in patients with acute inferior myocardial infarction and predominant right ventricular involvement. Cardiology. 1990;77(1):40-9. [Medline].

  31. Schuler G, Hofmann M, Schwarz F. Effect of successful thrombolytic therapy on right ventricular function in acute inferior wall myocardial infarction. Am J Cardiol. Nov 1 1984;54(8):951-7. [Medline].

  32. Sharpe DN, Botvinick EH, Shames DM. The noninvasive diagnosis of right ventricular infarction. Circulation. Mar 1978;57(3):483-90. [Medline].

  33. Silverman BD, Carabajal NR, Chorches MA. Tricuspid regurgitation and acute myocardial infarction. Arch Intern Med. Jul 1982;142(7):1394-5. [Medline].

  34. Zorio E, Arnau MA, Rueda J, Almenar L, Osa A, Martínez-Dolz L, et al. The presence of epsilon waves in a patient with acute right ventricular infarction. Pacing Clin Electrophysiol. Mar 2005;28(3):245-7. [Medline].

  35. Sugiura T, Iwasaka T, Shiomi K. Clinical significance of right ventricular dilatation in patients with right ventricular infarction. Coron Artery Dis. Dec 1994;5(12):955-9. [Medline].

  36. Tan HC, Yeo TC, Lim YT. A case of unusual electrocardiographic presentation of right ventricular myocardial infarction. Ann Acad Med Singapore. Nov 1997;26(6):844-7. [Medline].

  37. Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. Feb 5 2008;117(5):686-97. [Medline].

  38. Tobinick E, Schelbert HR, Henning H. Right ventricular ejection fraction in patients with acute anterior and inferior myocardial infarction assessed by radionuclide angiography. Circulation. Jun 1978;57(6):1078-84. [Medline].

  39. Vesterby A, Steen M. Isolated right ventricular myocardial infarction. A case report. Acta Med Scand. 1984;216(2):233-5. [Medline].

  40. Yoshino H, Udagawa H, Shimizu H. ST-segment elevation in right precordial leads implies depressed right ventricular function after acute inferior myocardial infarction. Am Heart J. Apr 1998;135(4):689-95. [Medline].

  41. Zeymer U, Neuhaus KL, Wegscheider K. Effects of thrombolytic therapy in acute inferior myocardial infarction with or without right ventricular involvement. HIT-4 Trial Group. Hirudin for Improvement of Thrombolysis. J Am Coll Cardiol. Oct 1998;32(4):876-81. [Medline].

  42. Inglessis I, Shin JT, Lepore JJ, Palacios IF, Zapol WM, Bloch KD, et al. Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock. J Am Coll Cardiol. Aug 18 2004;44(4):793-8. [Medline].

  43. Freas GC. Medicolegal aspects of acute myocardial infarction. Emerg Med Clin North Am. May 2001;19(2):511-21. [Medline].

  44. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation. Apr 1 2008;117(13):1717-31. [Medline].

  45. Saw J, Davies C, Fung A. Value of ST elevation in lead III greater than lead II in inferior wall acute myocardial infarction for predicting in-hospital mortality and diagnosing right ventricular infarction. Am J Cardiol. Feb 15 2001;87(4):448-50, A6. [Medline].

  46. Tsuka Y, Sugiura T, Hatada K. Clinical significance of ST-segment elevation in lead V1 in patients with acute inferior wall Q-wave myocardial infarction. Am Heart J. Apr 2001;141(4):615-20. [Medline].

  47. Zehender M, Kasper W, Kauder E. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med. Apr 8 1993;328(14):981-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

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

[ CLOSE WINDOW ]

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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.