Right ventricular infarction following myocardial infarction

Right ventricular infarction is a life-threatening complication that may accompany inferior myocardial infarction. It is suggested by electrocardiogram (ECG) evidence of ST elevation in lead V4R in the context of an inferior infarct, and is confirmed by echocardiography.

Clinical signs of isolated right ventricular infarction are those of right heart failure (ie raised jugular venous pressure) and signs of low cardiac output (ie hypotension, oliguria and possibly shock), but without pulmonary congestion (ie clear chest on auscultation and no radiographic evidence of congestion). Patients with these clinical signs should be given an intravenous fluid challenge, beginning cautiouslyGoldstein, 2002. Use:

While giving fluid, observe the patient closely for deteriorating haemodynamic status and development of left ventricular failure. Haemodynamic monitoring is helpful to guide therapy when:

• hypotension and oliguria do not respond promptly
• inotropic support is needed
• the relative contribution of left versus right ventricular dysfunction is unclear.

Use of glyceryl trinitrate, morphine or a beta blocker in the acute phase of right ventricular infarction may precipitate hypotension and cardiogenic shock.