Developed for the Cath Lab, ICU and ED to identify and care for MI patients properly

1. RV vs LV Myocardial Infarction
By Wendy Cooley RN BSN

2. RVMI and Coronary Circulation
 The majority of Right Ventricular Myocardial Infarction (RVMI) result from 100%
occlusion of the proximal Right Coronary Artery (RCA)
 RVMI is also associated with acute ST-elevation MI of the inferior wall of the LeftVentricle
as left dominant systems feed the RV in 15% of patients
 Therefore, in the presence of hypotension or cardiogenic shock without signs of LV
failure, a diagnosis of RVMI is highly probable
 Chronic lung disease and right ventricular hypertrophy are considered significant risk
factors for RVMI

3. Importance of Identification & Differentiation
 RVMI occur in about ~50% of all inferior MIs
 RVMI has a mortality rate of 23-30% BUT those who survive have a recovery
rate of 62-82% in the first few months
 LeadV4R is 90% specific to RVMI
 Therefore, literature suggests that every patient with ST ￪ in leads II, III & AVF
should have right-sided precordial lead ECG
 Because, proper identification leads to proper treatment which leads to tissue &
patient survival

4. Lead V4R

5. MI on the EKG

6. Coronary
Arteries as
they associate
with the ECG
 Inferior: RCA, PDA, PLV (Leads
II, III, aVF) Suspect RVMI
 Lateral: Circumflex (Leads I, aVL,
V5-V6*)
 Anterior: LAD, Diagonals, Septal
(Leads V1-V6*) Suspect LVMI
*Leads V5-6 can appear as lateral or anterior
depending on coronary anatomy. Often referred
to as an “Antero-lateral MI”

7. Blood pressure basics
Injured muscle from an MI can’t pump well. Depending on which ventricle is affected
will determine your treatment.
 Pre-load-Volume of blood at end diastolic in the RV
 After-load- Forward resistance that LV has to pump against
 StrokeVolume- Amount of blood pumped out with each beat
 Contractility- How well the heart contracts with each beat
 Cardiac Output- How much volume the heart ejects per minute
 Volume- Amount of blood in the system

8. Symptoms:
Chest Pain is still the most frequent symptom of MI in
addition to nausea/vomiting, diaphoresis, dizziness & anxiety
LVMI
LV has lost pumpability & cannot push to body
therefore blood will back up in the lungs:
 Pulmonary congestion
 New MV murmur
 CHF
 Flash pulmonary edema
 Cardiogenic shock
RVMI
RV has lost pumpability & cannot push to lungs
therefore blood will back up in the body:
 Clear lungs sounds
 Hypotension
 Jugular distention
 Bradycardia, possible vagal response
 Kussmaul’s respirations
 Pulsus paradoxus

9. MI and Arrhythmias
LVMI
 Ventricular tachycardia
 Ventricular fibrillation
 Tachycardia
Be ready to defibrillate
RVMI
 Third Degree Heart Block
 A.fib/flutter
 Bradycardia or Tachycardia
Be ready to transcutaneous pace

10. MI Mimics
LVMI
 Pericarditis
 LV Hypertrophy
 Early repolarization
 Hyperkalemia
RVMI
 Pulmonary Embolism
 Anterior- Septal MI
 Pericarditis

11. Emergent PCI & Specific Treatment
LVMI
1. Nitroglycerin
2. Morphine
3. Diuretics
4. Inotropes
5. Amiodarone/Lidocaine
6. Ventricular Support (IABP or LV
Impella)
Defibrillation if needed
RVMI
1. Fluids for Pre-load
2. Fluids for Pre-load (get the point here?)
3. Inotropes
4. Atropine
5. Ventricular Support (IABP or Impella both LV
or RV)
Temporary pacer if needed

12. Avoid in Inferior & RVMI
 Nitrates, opiods, diuretics: lower pre-load
 Beta-blockers: lower heart rate
 Calcium Channel Blockers: lower contractility

13. Bibliography
 Carter,T., & Keith, E. (2005,April). RightVentricular Infarction. Cardiovascular Medicine, 25(2),
52-62. Retrieved from http://ccn.aacnjournals.org/content/25/2/52.full.pdf
 Levin L, Goldstein JA. Right ventricular myocardial infarction. In: UpToDate, Post TW (Ed),
UpToDate,Waltham, MA. (Accessed on May 15, 2017.)
 Tomas, O., Kanovsky, J., Novotny,T.,Andrsova, I., Spinar, J., & Kala, P. (2013). Right ventricular
myocardial infarction: From pathophysiology to prognosis. Journal of Expiramental & Clinical
Cardiology, 18(1), 27-30. Retrieved from www.google.com

14. For more information:
Contact Wendy Cooley at
wcooley@mvhealthsystem.org