Dr. Gias Uddin Md Salim MD –Final Part Student Department of Cardiology Dhaka Medical College

1. Inferior myocardial infarction with Right
ventricular infarction & Posterior extension
Dr. Gias Uddin Md Salim
MD –Final Part Student
Department of Cardiology
Dhaka Medical College

2. A 60 year old women, diabetic and hypertensive patient
presented with H/O operation of carcinoma of breast on
4th POD
 Severe central chest tightness with epigastric discomfort
 Persistent for 2 hours,
 Associated with nausea, vomiting and severe shortness of
breath
 Calm and cold periphery, feeling of fainting with agitation.

3. Examination:
pulse: 108 b/min and feeble
BP: 80/50mmHg
JVP: elevated
Cyanosis present
Precordium: S1+S2,no murmur
Lungs: no basal crackles.
Temperature -101* F

4. ????

5. Possibilities:
 ACS
 Acute pulmonary embolism
 Pericardial effusion/temponade
 Pneumothorax/collapse lungs
 Metabolic causes

11. Artery involved in Inferior MI
 RCA(Right dominant)
 LCX(left dominant)
 Type 4 LAD

14. CLINICAL FEATURES
 Symptoms:
 Chest pain > 30 min.
 Character of the pain –retrosternal,
constrciting,crushing,compressing sensation of heavy
weight.
 Predilection for left side.
 Radiates to the ulnar aspect of the left arm
 Tingling sensation of the wrist and fingers.

15.  In some patients, the symptom is epigastric, with a
feeling of indigestion or of fullness and gas.
 Nausea,Vomitings , why more common?
 Profound weakness
 Dizziness
 Palpitations,
 Cold perspiration
 Sense of impending doom.
 Urine output

16. Isolated Inferior MI
 Clinical features?
 Hemodynamically stable or not?

17. If not ,think followings:
 RV infarction
 Post extension
 RV+Post extension
 Associated anterior MI
 Old MI
 Arrythmias
 Atrial infarction
 Drugs: beta blocker

18.  Pericardial Effuusion
 VSR
 Acute pulmonary embolism
 Acute severe mitral regurgitation
 Bezold–Jerisch reflex

19. Why detection of RV /post infarction is
important?

20. Why detection of RV /post infarction is important?
 Clinical presentation is different
 ECG over looked
 Conventional ECG leads not representative of those
surface
 Special leads require to perform ECG
 Management different than anterior,inferior ,posterior
 Some drugs should be avoided
 Fluids may be needed for management
 In Exam important (OSPE ECG. medicine &
cardiology)

21.  Isolated RV infarction is extremely rare.
 RVI usually is noted in association with
inferior wall MI.
 • The incidence of RVI in such cases ranges
from 10-50%

22.  AV block is more common than infranodal block and
occurs in approximately 20% of IWMI.
 Sinus bradycardia is more common in IWMI
(tahcycardia in AWMI)
 Posterior wall MI is associated with 5% of IWMI or
lateral MI but rarely occurs alone.

23.  <10% hemodynamic unstable
 Higher morbidity and mortality than inferior
MI
 Mortality 25-30% - Inferior mi + RVI = 31%
- Inferior mi – RVI = 6%
 RV infarcttion +LV failure -80%

24. Classic clinical triad of
 1. Distended neck veins (↑ JVP)
 2. Clear lung fields
 3. Hypotension.

25.  RV- S3, S4 +
– Lower left sternal border
– ↑with inspiration.
 • Hemodynamic monitoring.
– ↑right-sided filling pressures

26. hemodynamic features of RVI:
 Prominent V wave, sharp Y descent
 ↑in RA pressure (JVP) with inspiration (ie,Kussmaul
sign)
 • Fall in systolic pressure >10 mm Hg with
inspiration (ie,pulsus paradoxus)

27. Mimic/DD of RV infarction
 Hypotension(without JVP raised)
 Pericardial temponade
 Acute pulmonary embolism

28.  ECG
 Cardiac biomarkers
Troponin -I (disproportionately increased)
CKMB,
 CBP
 RBS
 CXR-signs of LV failure, help to fluid
therapy,PE,Effsion
 Serum electrolytes
 Serum creatinine
Investigations:

29.  Lipid profile
 Technetium 99m pyrophosphate scintigraphy
 Scintigraphy with thallium 201
 Hemodynamic assesement with PA catheter---
cardiogenic shock

30.  Inferior wall MI –
ST segment elevation of > 1 mm in inferior leads
then look the following leads (Which coronary artery?)
 ST segment elevation lead III>ST segment lead II-RCA
 Reciprocal change in lead I & aVL-RCA
 If no reciprocal change in lead I & aVL- LcX
 Signs of lateral infarction I,aVL,V5,V6-LcX
 Look anterior lead –LAD
ECG -----

31.  Then look for V1,V2,,V3,V4(Don’t Missed)
 In VI isoelectric/elevated
 V2,V3, V4 ST segment depression
 ST elevation in right sided chest lead(V3R/V4R)
----RV infarction
ECG -----

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

35.  R/S ratio >1 in V1 & V2
 ST depression
 T upright
 ST segment elevation in pV7,pV8 and pV9
----post extension
ECG ----

37. Position of post leads

53.  Is it inferior MI?

55. Echo
 Exclude d/d
 PE
 Acute pulmonary embolism

58. Hemodynamic Monitoring
 ↑↑Rt.-sided filling pressures as compared with
Lt-sided ---hallmark of RVI
 Hemodynamic criteria for RVI include
– RA pressure >10 mm Hg (CVP)
– Rt atrial–to–PCWP ratio >0.8

59.  MRI with gadolinium contrast enhancement –most
sensitive –2 gm of MI can be detected.
 Techntium scan – hot spot with calcium – insensitive
to small infarctions.
 Thallium scan –cold spots in regions of diminished
perfusion –does not differentiate old from new.
Other imaging

60. Principle of Management:
 Management of ACS
 Maintain RV preload
 Lower RV afterload
 Restore AV synchrony
 Arrythmias
 Inotropic support
 Risk factors
 Mobilization & rehabilitation

62. Initial management
 Complete bed rest
 High flow O2
 Loading dose of aspirin, clopidogrel, statin
 IV channel
 Analgesic
 Antiemetic
 Continuous ECG monitoring
 CV and arterial line insertion and monitoring of CVP
 Alternate to CVP—JVP,Lungs crakles

63. management
Primary PCI
Pharmaco- invasive
Reperfusion with Thrombolysis
Fluid challange
Inj.Atropine
pulse,BP, JVP, Lungs,Urine output-hourly
Antidiabetic with short acting insulin
Risk stratification (TIMI /GRACE risk score)

66. Caution…
 Nitrates
 Beta blocker, rate limiting CCB
 Vasodilators
 Diuretic
 Opiods(morphine)

67. Cardiogenic shock with RVI
Target: CVP:8-10mmHg or PCWP:18mmHg
Early reperfusion should achieved if possible
RV preload should be optimized by:
Fluid challenge:(Fluid in fluid)
Inotropes: dobutamine.
RV after load should be optimized when associated with
LV dysfunction.

69. Management of RV Infarction
 Fluids challenges

70. Management of RV Infarction
Fluids challenges
 Normal saline
 Careful administration of fluid boluses
 Bolus 200-300 ml running(aliquts),several liters in one
hour,
 Frequently auscultate lungs bases
 Upto-1500mL; then measure
 PCWP-<15 mm of hg
 Continue fluid
 Not responded to fluid?/

71.  • RV failure may limit filling via ↓in CO,
 • Traditionally -focused on ensuring adequate
Rt-sided filling pressures to maintain CO and
adequate LV preload.
 • Pts with cardiogenic shock due to RV
dysfunction have very high RV-EDP, often >20
mm Hg
Right Ventricular Dysfunction and
Shock, use of excessive fluids??

72.  This elevation of RV-EDP may result in shifting
of the IVS toward the LV cavity
 Which raises LA 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.
 The common practice of aggressive fluid
resuscitation for RV dysfunction in shock may be
misguided.

73.  Inotropic support(principle?)
 Dobutamine, 2 to 5 μg per kg per minute given IV, with
dose increased every 5 to 10 minutes up to 15 to 20 μg per
kg per minute (why?)
 Milrinone
 Levosimendan (approved only in Europe)
 Norepinephrine
 Low-dose vasopressin.
 Nitropruside and hydralazine
 Avoid dopamine(?) and phenylephrine(?).
 Consider combination therapy with inhaled
nitric oxide.

74. Inhaled Nitric Oxide
 Inhaled NO – in pts with RVI complicated by
cardiogenic shock.
 Principle- ↓PVR without compromising SVR, the
filling of the LV can be improved with a resultant
improvement of systemic CO.
 Inhaled NO in this setting has been associated with
rapid improvement of hemodynamics.
 The combination of inhaled NO with dobutamine is
best supported by current evidence in the treatmen of
acute RV failure.

75. Rate and rhythm control
 Symptomatic bradycardia: atropine, 0.5 to 1 mg given IV
every 5 minutes up to total of 2.5 mg
 Salbutamol
 Theophyline
 propantheline
 Isoprenaline
 A-V sequential pacing is the modality of choice
when a pacemaker is required

76. Other options:
 Nitroprusside,hydralazine infusion for afterload
reduction.
 IABP- Concomitant LV dysfunction
 Mechanical circulatory support can be also
used, including-
1. LVAD
2. RVAD
3. Biventricular ventricular assist device.
 pericardiotomy

77.  RV is a thin-walled chamber that functions at low
O2 demands and pressure.
 It is perfused throughout the cardiac cycle in both systole
and diastole.
 Its ability to extract O2 is increased during
hemodynamic stress.
 Collateral blood supply ( Esp. anterior wall of
RV)
 All of these factors make the RV less susceptible
to infarction than the LV
Is it reversible ?less
extensive

78. Risk factors Mx
Control DM and HTN
Cessation of smoking
Low fat diet
Eat more vegetables, fruits and fiber containing foods
Control body weight
Regular walking and exercise

79. Mobilization and Rehabilitation
In uncomplicated cases:
 Sit on the chair in Day2
 Walk to toilet Day3
 Return to home on Day 5-7
 To normal work 4-6 wks
 Counseling and reassurance
Complicated cases:
 Process of mobilization and rehabilitation varies and
depends upon the patient functional capacity.

80. যাহা কিছু মনে রাকিনে হইনে
Inferior MI(ST elevation in II,III,aVF)
1. Look for RV & Post extension(V1-V4)
2. Do rt site & post ECG
3. Look for arrythmias
4. Fluid challange
5. Avoid drugs (nitrates,diuretics,b –
blocker,vasodilator)
6. Ionotrops(dobutamine)

81. OSPE??

83.  Write down the complete ECG diagnosis
 Write the three points in favour of your diagnosis
 What do you expect in auscultation of lung base
 Mention 2 other positive clinical findings support
your diagnosis
 What is the site of lesion
 Mention one treatment option usually not given in
lesion of he other site

84. Thank you
??