Sections

Medication

Medication Summary

The goals of pharmacotherapy for right ventricular infarction are to reduce morbidity and prevent complications. Cardiovascular agents included in treatment are reperfusion agents (ie, tissue plasminogen activators) and inotropic agents.^{[4, 8]}

Class Summary

Inotropic therapy is indicated for right ventricular failure when cardiogenic shock persists after right ventricular end-diastolic pressure has been optimized. Inotropes should be used until more data are available. Dobutamine is an inotropic agent used to improve right ventricular contractility and maintain cardiac output.

Dobutamine (Dobutrex)

View full drug information

Dobutamine produces vasodilation and increases the inotropic state. At higher dosages, this agent may cause increased heart rate, exacerbating myocardial ischemia.

Milrinone

View full drug information

Milrinone is a bi-pyridine positive inotrope and vasodilator with little chronotropic activity. It is different in mode of action from both digitalis glycosides and catecholamines. It selectively inhibits phosphodiesterase type III (PDE III) in cardiac and smooth vascular muscle, resulting in reduced afterload, reduced preload, and increased inotropy.

Class Summary

Tissue plasminogen activators bind to fibrin and convert plasminogen to plasmin, which in turn initiates local fibrinolysis with limited systemic proteolysis. Thrombolytic therapy may contribute to an early survival benefit in patients presenting within 6 hours of onset of onset of inferior wall myocardial infarction with right ventricular involvement diagnosed by ECG or other noninvasive criteria.

Alteplase (Activase)

View full drug information

Alteplase is a tissue plasminogen activator used in the management of acute myocardial infarction, acute ischemic stroke, and pulmonary embolism. Heparin or aspirin may be administered with and after alteplase infusions to reduce the risk of rethrombosis. The safety and efficacy of concomitant administration of heparin or aspirin during the first 24 hours after symptom onset have not been investigated.

Reteplase (Retavase)

View full drug information

Reteplase is a recombinant plasminogen activator that forms plasmin after facilitating cleavage of endogenous plasminogen. It is used in the management of acute myocardial infarction. Heparin or aspirin may be administered with and after reteplase infusions.

Class Summary

Adrenergic agonists stimulate beta- and alpha-adrenergic receptors, causing increased contractility and heart rate, as well as vasoconstriction. These actions increase systemic blood pressure and coronary blood flow.

Norepinephrine (Levophed)

View full drug information

Norepinephrine is a naturally occurring catecholamine with potent alpha-receptor and mild beta-receptor activity. It stimulates beta1- and alpha-adrenergic receptors, resulting in increased cardiac muscle contractility, heart rate, and vasoconstriction. It increases blood pressure and afterload. Increased afterload may result in decreased cardiac output, increased myocardial oxygen demand, and cardiac ischemia.

Class Summary

Antidiuretic hormone analogs increase cyclic adenosine monophosphate (cAMP), increasing water permeability at the renal tubules. An example of this analog is vasopressin, which is a direct vasoconstrictor without inotropic or chronotropic effects.

Vasopressin (Pitressin)

View full drug information

Vasopressin increases water resorption at the distal renal tubular epithelium (ADH effect). It promotes smooth muscle contraction throughout the vascular bed of the renal tubular epithelium (vasopressor effects). Vasoconstriction is also increased in splanchnic, portal, coronary, cerebral, peripheral, pulmonary, and intrahepatic vessels.

Questions

Chockalingam A, Gnanavelu G, Subramaniam T, Dorairajan S, Chockalingam V. Right ventricular myocardial infarction: presentation and acute outcomes. Angiology. 2005 Jul-Aug. 56(4):371-6. [QxMD MEDLINE Link].
Forman MB, Goodin J, Phelan B, Kopelman H, Virmani R. Electrocardiographic changes associated with isolated right ventricular infarction. J Am Coll Cardiol. 1984 Sep. 4(3):640-3. [QxMD MEDLINE Link].
Garty I, Barzilay J, Bloch L, Antonelli D, Koltun B. The diagnosis and early complications of right ventricular infarction. Eur J Nucl Med. 1984. 9(10):453-60. [QxMD MEDLINE Link].
Giannitsis E, Potratz J, Wiegand U, Stierle U, Djonlagic H, Sheikhzadeh A. Impact of early accelerated dose tissue plasminogen activator on in-hospital patency of the infarcted vessel in patients with acute right ventricular infarction. Heart. 1997 Jun. 77(6):512-6. [QxMD MEDLINE Link]. [Full Text].
Haupt HM, Hutchins GM, Moore GW. Right ventricular infarction: role of the moderator band artery in determining infarct size. Circulation. 1983 Jun. 67(6):1268-72. [QxMD MEDLINE Link].
Hirsowitz GS, Lakier JB, Goldstein S. Right ventricular function evaluated by radionuclide angiography in acute myocardial infarction. Am Heart J. 1984 Oct. 108(4 Pt 1):949-54. [QxMD MEDLINE Link].
Hurst JW. Comments about the electrocardiographic signs of right ventricular infarction. Clin Cardiol. 1998 Apr. 21(4):289-91. [QxMD MEDLINE Link].
Iqbal MZ, Liebson PR. Counterpulsation and dobutamine. Their use in treatment of cardiogenic shock due to right ventricular infarct. Arch Intern Med. 1981 Feb. 141(2):247-9. [QxMD MEDLINE Link].
Kinn JW, Ajluni SC, Samyn JG, Bates ER, Grines CL, O'Neill W. Rapid hemodynamic improvement after reperfusion during right ventricular infarction. J Am Coll Cardiol. 1995 Nov 1. 26(5):1230-4. [QxMD MEDLINE Link].
Bates ER. Revisiting reperfusion therapy in inferior myocardial infarction. J Am Coll Cardiol. 1997 Aug. 30(2):334-42. [QxMD MEDLINE Link].
Andersen HR, Nielsen D, Falk E. Right ventricular infarction: larger enzyme release with posterior than with anterior involvement. Int J Cardiol. 1989 Mar. 22(3):347-55. [QxMD MEDLINE Link].
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. 1987 Dec. 10(6):1223-32. [QxMD MEDLINE Link].
Andersen HR, Nielsen D, Lund O, Falk E. Prognostic significance of right ventricular infarction diagnosed by ST elevation in right chest leads V3R to V7R. Int J Cardiol. 1989 Jun. 23(3):349-56. [QxMD MEDLINE Link].
Birnbaum Y, Wagner GS, Barbash GI, et al. 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. 1999 Jan 15. 83(2):143-8. [QxMD MEDLINE Link].
Braat SH, Brugada P, den Dulk K, van Ommen V, Wellens HJ. Value of lead V4R for recognition of the infarct coronary artery in acute inferior myocardial infarction. Am J Cardiol. 1984 Jun 1. 53(11):1538-41. [QxMD MEDLINE Link].
Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J. 1983 Apr. 49(4):368-72. [QxMD MEDLINE Link]. [Full Text].
Elkayam U, Halprin SL, Frishman W, Strom J, Cohen MN. Echocardiographic findings in cardiogenic shock due to right ventricular myocardial infarction. Cathet Cardiovasc Diagn. 1979. 5(3):289-94. [QxMD MEDLINE Link].
Lisbona R, Sniderman A, Derbekyan V, Lande I, Boudreau R. Phase and amplitude imaging in the diagnosis of acute right ventricular damage in inferior infarction. Clin Nucl Med. 1983 Nov. 8(11):517-20. [QxMD MEDLINE Link].
Martin W, Tweddel A, McGhie I, Hutton I. The evaluation of right ventricular function in acute myocardial infarction by xenon-133. Nucl Med Commun. 1989 Jan. 10(1):35-43. [QxMD MEDLINE Link].
Mittal SR. Isolated right ventricular infarction. Int J Cardiol. 1994 Aug. 46(1):53-60. [QxMD MEDLINE Link].
Silverman BD, Carabajal NR, Chorches MA, Taranto AI. Tricuspid regurgitation and acute myocardial infarction. Arch Intern Med. 1982 Jul. 142(7):1394-5. [QxMD MEDLINE Link].
Nader DA, Ceretto WJ, Vieweg WV. Atrial pacing in the management of right ventricular infarction. South Med J. 1981 Mar. 74(3):362-3. [QxMD MEDLINE Link].
Pfisterer M, Emmenegger H, Muller-Brand J, Burkart F. Prevalence and extent of right ventricular dysfunction after myocardial infarction--relation to location and extent of infarction and left ventricular function. Int J Cardiol. 1990 Sep. 28(3):325-32. [QxMD MEDLINE Link].
Sugimoto T, Ogawa K, Asada T, et al. Surgical treatment of ventricular septal perforation with right ventricular infarction. J Cardiovasc Surg (Torino). 1996 Feb. 37(1):71-4. [QxMD MEDLINE Link].
Mavric Z, Zaputovic L, Matana A, et al. Prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and without right ventricular involvement. Am Heart J. 1990 Apr. 119(4):823-8. [QxMD MEDLINE Link].
Tomala M, Miszalski-Jamka T, Zajdel W, et al. Angiographic result of index PCI determines the presence of right ventricular infarction in patients with acute inferior myocardial infarction. Int J Cardiovasc Imaging. 2015 Dec. 31 (8):1591-601. [QxMD MEDLINE Link].
Lahm T, McCaslin CA, Wozniak TC, et al. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol. 2010 Oct 26. 56(18):1435-46. [QxMD MEDLINE Link].
Singhal AM, Ilangovan S, Mehta S, Portaluppi F. Isolated right ventricular infarction followed by posterior left ventricular infarction after a few days. Acta Cardiol. 1984. 39(4):307-12. [QxMD MEDLINE Link].
Strauss HD, Sobel BE, Roberts R. The influence of occult right ventricular infarction on enzymatically estimated infarct size, hemodynamics and prognosis. Circulation. 1980 Sep. 62(3):503-8. [QxMD MEDLINE Link].
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. 2005 May 1. 95(9):1039-42. [QxMD MEDLINE Link].
Chockalingam A, Gnanavelu G, Alagesan R, Subramaniam T. Myocardial performance index in evaluation of acute right ventricular myocardial infarction. Echocardiography. 2004 Aug. 21(6):487-94. [QxMD MEDLINE Link].
Robalino BD, Petrella RW, Jubran FY, Bravo EL, Healy BP, Whitlow PL. Atrial natriuretic factor in patients with right ventricular infarction. J Am Coll Cardiol. 1990 Mar 1. 15(3):546-53. [QxMD MEDLINE Link].
Roth A, Miller HI, Kaluski E, et al. 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. [QxMD MEDLINE Link].
Schuler G, Hofmann M, Schwarz F, et al. Effect of successful thrombolytic therapy on right ventricular function in acute inferior wall myocardial infarction. Am J Cardiol. 1984 Nov 1. 54(8):951-7. [QxMD MEDLINE Link].
Sharpe DN, Botvinick EH, Shames DM, et al. The noninvasive diagnosis of right ventricular infarction. Circulation. 1978 Mar. 57(3):483-90. [QxMD MEDLINE Link].
Zorio E, Arnau MA, Rueda J, et al. The presence of epsilon waves in a patient with acute right ventricular infarction. Pacing Clin Electrophysiol. 2005 Mar. 28(3):245-7. [QxMD MEDLINE Link].
Tobinick E, Schelbert HR, Henning H, et al. Right ventricular ejection fraction in patients with acute anterior and inferior myocardial infarction assessed by radionuclide angiography. Circulation. 1978 Jun. 57(6):1078-84. [QxMD MEDLINE Link].
Lupi-Herrera E, Gonzalez-Pacheco H, Juarez-Herrera U, et al. Primary reperfusion in acute right ventricular infarction: An observational study. World J Cardiol. 2014 Jan 26. 6(1):14-22. [QxMD MEDLINE Link]. [Full Text].
Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008 Feb 5. 117(5):686-97. [QxMD MEDLINE Link].
Vesterby A, Steen M. Isolated right ventricular myocardial infarction. A case report. Acta Med Scand. 1984. 216(2):233-5. [QxMD MEDLINE Link].
Yoshino H, Udagawa H, Shimizu H, et al. ST-segment elevation in right precordial leads implies depressed right ventricular function after acute inferior myocardial infarction. Am Heart J. 1998 Apr. 135(4):689-95. [QxMD MEDLINE Link].
Zeymer U, Neuhaus KL, Wegscheider K, Tebbe U, Molhoek P, Schroder R. 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. 1998 Oct. 32(4):876-81. [QxMD MEDLINE Link].
Inglessis I, Shin JT, Lepore JJ, et al. Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock. J Am Coll Cardiol. 2004 Aug 18. 44(4):793-8. [QxMD MEDLINE Link].
Kretzschmar D, Lauten A, Ferrari MW. In vitro evaluation of a novel pulsatile right heart assist device - the PERKAT system. Int J Artif Organs. 2015 Nov 10. 38 (10):537-41. [QxMD MEDLINE Link].
[Guideline] Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012 Oct. 33 (20):2569-619. [QxMD MEDLINE Link]. [Full Text].
Yaylak B, Ede H, Baysal E, et al. Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST elevation myocardial infarction. Cardiol J. 2015 Sep 28. [QxMD MEDLINE Link].
Sugiura T, Iwasaka T, Shiomi K, Nagahama Y, Takehana K, Inada M. Clinical significance of right ventricular dilatation in patients with right ventricular infarction. Coron Artery Dis. 1994 Dec. 5(12):955-9. [QxMD MEDLINE Link].
Tan HC, Yeo TC, Lim YT, Chia BL. A case of unusual electrocardiographic presentation of right ventricular myocardial infarction. Ann Acad Med Singapore. 1997 Nov. 26(6):844-7. [QxMD MEDLINE Link].
Nourian S, Hosseinsabet A, Jalali A, Mohseni-Badalabadi R. Evaluation of right atrial function by two-dimensional speckle-tracking echocardiography in patients with right ventricular myocardial infarction. Int J Cardiovasc Imaging. 2016 Sep 8. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Claudia Dima, MD, FACC Interventional Cardiology

Disclosure: Nothing to disclose.

Coauthor(s)

David L Coven, MD, PhD Assistant Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons; Director, Cardiology Outpatient Clinic, St Luke’s Site, Attending Physician, Department of Medicine, Division of 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, Massachusetts Medical Society

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic ArizonA

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Additional Contributors

Kenneth B Desser, MD  Former Clinical Professor, Director of Cardiology Fellowship, Banner Good Samaritan Medical Center

Disclosure: Nothing to disclose.

George A Stouffer, III, MD Ernest and Hazel Craige Distinguished Professor of Medicine and Cardiology, Chief 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, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Rex C Liu, MD, to the development and writing of the source article.

Leads	Sensitivity (%)	Specificity (%)
V₁	28	92
V₃ R	69	97
V₄ R	93	95

Right Ventricular Infarction Medication

Medication Summary

Inotropic Agents

Class Summary

Dobutamine (Dobutrex)

Dobutamine (Dobutrex)

Milrinone

Milrinone

Tissue Plasminogen Activators

Class Summary

Alteplase (Activase)

Alteplase (Activase)

Reteplase (Retavase)

Reteplase (Retavase)

Adrenergic Agonists

Class Summary

Norepinephrine (Levophed)

Norepinephrine (Levophed)

Antidiuretic Hormone Analogs

Class Summary

Vasopressin (Pitressin)

Vasopressin (Pitressin)

Right Ventricular Infarction Medication

Medication Summary

Inotropic Agents

Class Summary

Dobutamine (Dobutrex)

Dobutamine (Dobutrex)

Milrinone

Milrinone

Tissue Plasminogen Activators

Class Summary

Alteplase (Activase)

Alteplase (Activase)

Reteplase (Retavase)

Reteplase (Retavase)

Adrenergic Agonists

Class Summary

Norepinephrine (Levophed)

Norepinephrine (Levophed)

Antidiuretic Hormone Analogs

Class Summary

Vasopressin (Pitressin)

Vasopressin (Pitressin)

References

Tables

Contributor Information and Disclosures

What would you like to print?