Right Ventricular Infarction Clinical Presentation

Updated: Mar 29, 2017
  • Author: Claudia Dima, MD, FACC; Chief Editor: Eric H Yang, MD  more...
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Presentation

History

Although right ventricular infarction occurs in more than 30% of patients with inferior posterior left ventricular myocardial infarction, hemodynamically significant right ventricular infarction occurs in less than 10% of these patients. [18, 19]

A right ventricular infarct should be considered in all patients who present with an acute inferior wall myocardial infarction, especially in the setting of a low cardiac output.

Patients may describe symptoms consistent with hypotension. A subtle clue to the presence of hemodynamically significant right ventricular infarction is a marked sensitivity to preload-reducing agents such as nitrates, morphine, or diuretics. [20] Other presentations include high-grade atrioventricular block, tricuspid regurgitation, [21] cardiogenic shock, right ventricular free wall rupture, and cardiac tamponade.

Should a patient with right ventricular infarction experience unexplained hypoxia despite administration of 100% oxygen, right-to-left shunting at the atrial level—through a patent foramen ovale or an atrial septal defect—in the presence of right ventricular failure and increased right atrial pressure must be considered. [22, 23]  

Patients with extensive right ventricular necrosis are at risk for right ventricular catheter–related perforation, and passage of a catheter or pacemaker in the chamber must always be performed with great care. [24]

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Physical Examination

The classic clinical triad of right ventricular infarction includes distended neck veins, clear lung fields, and hypotension. [25]

Infrequent clinical manifestations include right ventricular third and/or fourth heart sounds, which are typically audible at the left lower sternal border and increase with inspiration.

On hemodynamic monitoring, disproportionate elevation of right-sided filling pressures compared with left-sided hemodynamics represents the hallmark of right ventricular infarction.

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