Right Ventricular Infarction

Background

• Right ventricular (RV) infarction is caused by occlusion of arteries supplying blood to the right ventricle and is usually associated with inferior ST-elevation myocardial infarction.
• It can present with life-threatening complications (such as cardiogenic shock, arrhythmias, or heart block).

Evaluation

• Suspect right ventricular (RV) infarction in patients with ST-elevation myocardial infarction and severe hypotension or cardiogenic shock and elevated jugular venous pressure but clear lungs (with minimal or no left ventricular dysfunction).
• Obtain an electrocardiogram with additional right-sided leads to evaluate for RV infarction in all patients with inferior wall ST-elevation myocardial infarction (Strong recommendation).
• Consider imaging studies such as transthoracic echocardiography to evaluate right ventricular function.
• Consider right heart catheterization, where criteria for hemodynamically significant right ventricular myocardial infarction include:
  • right atrial pressure (RAP) > 10 mm Hg
  • RAP to pulmonary capillary wedge pressure (PCWP) ratio > 0.8
  • RAP within 5 mm Hg of PCWP

Management

• Perform early revascularization if possible in patients with acute myocardial infarction and significant right ventricular (RV) dysfunction (Strong recommendation).
• Maintain atrioventricular synchronicity and correct bradycardia (Strong recommendation).
• Consider administration of atropine for symptomatic bradycardia (Weak recommendation):
  • first dose 0.5 mg bolus (doses < 0.5 mg may paradoxically decrease heart rate)
  • repeat every 3-5 minutes
  • maximum dose 3 mg
• Consider transcutaneous pacing if bradycardia is unresponsive to atropine in unstable patients while patient is prepared for emergent transvenous temporary pacing (Weak recommendation).
• Consider transvenous pacing if patient does not respond to drugs or transcutaneous pacing (Weak recommendation).
• Administer 300-600 mL normal saline over 10-15 minutes to correct hypotension and optimize RV afterload in patients without pulmonary congestion or elevated jugular venous distension (Strong recommendation).
• Use inotropic support for patients with hemodynamic instability not responsive to volume challenge (Strong recommendation):
  • dobutamine is the preferred agent due to least deleterious effects on afterload, oxygen consumption, and arrhythmias; initial dose 0.5-1 mcg/kg/minute IV, titrate according to hemodynamic response and tolerability (range: 2-40 mcg/kg/minute)
  • dopamine or other agents with pressor effects may be used in patients with severe hypotension; initial dose 2-5 mcg/kg/minute IV, titrate according to hemodynamic response and tolerability in 5-10 mcg/kg/minute increments (maximum dose: 50 mcg/kg/minute)
• Optimize RV afterload (usually required therapy for concomitant left ventricular dysfunction) (Strong recommendation).