1. An 86-year-old female patient presented with chest pain, difficulty breathing, and general weakness. ECG results at the ambulance and hospital pointed to a diagnosis of posterior inferior myocardial infarction involving both the left and right ventricles. 2. She had multiple risk factors for heart disease including longstanding hypertension, diabetes, and atherosclerosis. 3. Intensive treatment in the ICU focused on fluid resuscitation, inotropes, and medications to stabilize her hemodynamics and support organ function as she presented with cardiogenic shock on admission.

1. LUGANSK STATE MEDICAL
UNIVERSITY
DEPARTMENT OF INTERNAL MEDICINE
TOPIC: RIGHT VENTRICULAR
MYOCARDIAL INFARCTION
BY: DR. IBEANU CHARLES
LUGANSK 2012

2. EPIDEMIOLOGY
In Ukraine, statistics shows that about 30% of all
myocardial infarction is with right ventricular involvement
and the combination of both left posterior and right
myocardial infarction is about 50% of all cases. It is
common in old age. In about 5% of right myocardial
infarction there is presence of cardiogenic shock. After
cardiogenic shock it progresses to right myocardial
infarction in 75% case.

3. ETIOLOGY
Atherosclerosis
Hypertension
Hypercholesterolemia
Progressive after left ventricular infarction

4. Risk factors
Non-Modification:
Age (>65 years)
Gender (50:50; male/female)
Genetic predisposition
Modification:
High risk coronary problem (Atherosclerosis)
Hypertensive history
Obesity
Diabetes mellitus
Hypodynamia
Alcohol consumption
Diet

5. PATHOPHYSIOLOGY OF RVMI
The right ventricle is a thin-walled chamber that functions at low oxygen demands
and pressure. It is perfused throughout the cardiac cycle in both systole and
diastole, and its ability to extract oxygen is increased during hemodynamic stress.
All of these factors make the right ventricle less susceptible to infarction than the
left ventricle.
The posterior descending branch of the right coronary artery usually supplies the
inferior and posterior walls of the right ventricle. The marginal branches of the right
coronary artery supply the lateral wall of the right ventricle. The anterior wall of the
right ventricle has a dual blood supply: the conus branch of the right coronary
artery and the moderator branch artery, which courses from the left anterior
descending artery.
Interestingly, right ventricular infarction noted at necropsy usually involves the
posterior septum and posterior wall rather than the right free wall. The relative
sparing of the right ventricular anterior wall apparently arises from a high degree of
collateralization. This collateral blood flow is thought to be derived from the
thebesian veins and diffusion of oxygen directly from the ventricular cavity. A direct
correlation exists between the anatomic site of right coronary artery occlusion and
the extent of right ventricular infarction. Studies have demonstrated that more
proximal right coronary artery occlusions result in larger right ventricular
infarctions.On occasion, the right ventricle can be subjected to infarction from
occlusion of the left circumflex coronary artery.

6. CASE STUDY CONDUCTED IN
HOSPITAL 7
PASSPORT PART:
Name: Patient X
Age: 86years
Sex: Female
Occupation: Pensioner

7. Present complain:
General weakness
Dizziness
Severe chest pain (>30mins) radiates to the left
arm, intrascapular region and neck
Difficulty in breathing
Anamnesis Morbi:
The patient arrived the hospital in an ambulance after which
the patient was hospitalized in Intensive care unit (ICU) on the
24th september after 2hours of intensive clinical picture which
occurred for the first time. The diagnosis after ECG in the
ambulance was diaphragmatic myocardial infarction with
subendocardial ischemia of the apex and lateral left ventricle
and sinus bradycardia (46 bpm)

8. Anamnesis Vitae:
The patient has 17 years history of arterial hypertension
with maximum blood pressure of 180/100 mmHg and
130/90 mmHg during normal life. The patient had diabetes
mellitus type II for 10 years with absence of regular
treatment, the patient occasionally took metformin
500mg/daily in the evening for 10 years. The patient was
diagnosed with atherosclerosis in 2004. The patient has
transitory ischemia of the brain for 8 years . There was
presence of ischemic heart disease for 10years and was
diagnosed to be sternocardia II stage and no specific
treatment was given. The patient has non-obstructive
chronic pulmonary disease with absence of treatment.
There was absence of tuberculosis, Botkin’s
disease, Malaria, Helminthosis, and any allergic disease.

9. ECG AT THE AMBULANCE

11. AV block in III lead, elevation of ST segment by 5mm in
leads II, III, AVF & V1, depression of ST segment in I, AVL
& reciprocal in V2 & V6. Rhythm of P wave and QRS
complex are 75 & 45 per minute respectively.

12. At Hospitalization in ICU
Anamnesis:
Presence of syncope, acrocyanosis of the lip, fingers and nose, cold feet and hands
After Auscultation of lung: absence of crepitation in lungs, tachypnea (16
beat/minutes)
After Auscultation of heart: sinus bradycardia, BP; 80/60
Laboratory findings:
Blood: WBC- 11.7 x 109 /L
Blood glucose: 9.0 mmol/L
Creatinine: 166 mg/dL
There was stabilization of haemodynamics after administration of:
Intravenous atropine 0.1%-1ml
Fluid upload (reosorbilact 400ml and Nacl 400ml)
Prednisolone 60mg and Nacl 100ml
Dopamine infusion 10mcg/kg/min
Oxygen therapy
Total infusion at admission in initial phase was about 1000ml while total fluid
upload possible is1500ml
Medications contraindicated in treatment of RVMI:
Diuretics
Nitrates
Narcotic agent: Morphine

13. INTENSIVE CARE UNIT
AV block in III lead, elevated ST segment in V3,V4, Q(+)
ST elevation in III lead. In Right position ECG; ST
elevation, ventricular extrasystole (bigeminy) & QRST
elevation.

14. STATUS PRESENT:
Respiratory: dyspnea, breathing rate-16 breaths per
minutes . On auscultation; absence of crepitation
Cardiovascular: Angina status, increased jugular venous
pressure, decreased blood pressure – 70/40, On
percussion; shift of left relative heart border by
1.5cm, edema
Digestive system: Liver enlargement(hepatomegaly-
+2.5cm in right) on palpation, the stomach and other
organs were said to be normal

15. LABORATORY DIAGNOSIS
Blood
1st day
Hemoglobin: 128
Leukocyte: 10.3 x 109 /L
ESR: 8mm/hr
Lymphocyte: 23%
5th day
Hemoglobin: 121
Leukocyte: 3.8 x 109 /L
ESR: 28mm/hr
Biochemical analysis
Troponin I: 43ng/mL
Lipid: 6mmol/l
Alfa cholesterol: 0.37mmol/L
Total cholesterol: 6.85mmol/L
Beta cholesterol: 4.6mmol/L
Pre-Beta cholesterol: 1.03mmol/L
Triglyceride: 1.6
AI: 4.8
Creatinine: 166 mg/dL
In Urine: Protein: 0.6

16. AFTER 2 HOURS
AV block, no extrasystole, ST depression in
line, T inverted and decrease reciprocal
problem in anterior and AVL

17. AFTER 50 MINUTES
AV block stage II and ST elevation

18. AFTER TREATMENT IN ICU
Sinus rhythm , normal position heart. Rhythm 71/min. In III
and AVF present Q(+) MI and T inverted in V4, V5, V6 right
position ECG not present in the slide.

19. ECHOCARDIOGRAM

20. DIAGNOSIS
Ischemic heart disease
Acute Q(+) myocardial infarction (Left Posterior diaphragmatic and
right ventricle MI) on 24th september 2012
Diffuse cardiosclerosis
Essential hypertension III stage (myocardial infarction, left ventricular
hypertrophy, coronary disease stage III and transitory ischemic attack
in 2004)
Heart decompensation stage IIa, Acute left ventricular dysfunction
killip IV ( cardiogenic shock), systolic dysfunction left ventricle.
Systolic fraction-38%
AV block stage III, normalization of sinus rhythm on the 30th of
september.
Diabetes mellitus type II (compensatory stage) and decirculatory
encephalopathy
Asthenic vegetative syndrome

21. TREATMENT IN HOSPITAL/HOME
Cardiomagnil 75mg, 1 tablet in the evening
Atovastatin 20mg, 1 tablet in the evening
Ramipril 5mg, 1 tablet in the morning
Eplerenone (inspra) 25mg, after breakfast everyday for
chronic treatment and to control potassium level in blood
Clopidogrel 75mg, everyday in the evening
Metabolic treatment; Trimetazidine 35mg, 2 times a day for
6months
Nitrate therapy after stabilization
Diabetone 30mg, 30 minutes before breakfast

22. SUMMARY
1. Patient after posterior inferior MI acute stage, problem in
proper diagnosis by ECG at the ambulance but standard
right position ECG shows specific diagnostic criteria in V3R
and V4R
2. Patient has acute posterior myocardial infarction and
acute right ventricular myocardial infarction. At admission
specific clinical picture; decrease BP, no
crepitation, increase JVP.
3. The anatomical substrate for right ventricular MI-is
characterized by proximal occulsion dominant in right
coronary artery and high risk cardiogenic shock and lethal
condition in prognosis.
4. Treatment of the patient in the ambulance was to
increase volume infusion and absence of diuretic, nitrate
and morphine therapy