Right ventricular myocardial infarction
- Thomas Levin, MD
Thomas Levin, MD
- Illinois Heart and Vascular
- Chicago, Illinois
- James A Goldstein, MD
James A Goldstein, MD
- Professor of Medicine
- Oakland University William Beaumont Hospital School of Medicine
- Section Editors
- Freek Verheugt, MD, FACC, FESC
Freek Verheugt, MD, FACC, FESC
- Section Editor — Coronary Heart Disease
- Onze Lieve Vrouwe Gasthuis, Netherlands
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Acute myocardial infarction (MI) involving only the right ventricle is an uncommon event. More often, right ventricular MI (RVMI) is associated with acute ST-elevation myocardial infarction of the inferior wall of the left ventricle, and occurs in 30 to 50 percent of such cases [1-6].
RVMI is associated with higher in-hospital morbidity and mortality compared with patients with a similar infarction territory in the left ventricle but that does not involve the right ventricle. Poor outcome is usually related to profound hemodynamic and electrical complications, which occur in approximately 50 percent of affected individuals [1-9]. However, long-term prognosis is generally good for those who survive the event.
This topic will discuss the diagnosis and management of patients with RVMI. The general approach to patients with MI is found elsewhere. (See "Overview of the acute management of non-ST elevation acute coronary syndromes" and "Overview of the acute management of ST elevation myocardial infarction" and "Overview of the non-acute management of ST elevation myocardial infarction" and "Overview of the non-acute management of unstable angina and non-ST elevation myocardial infarction".)
Definitions — The following terms that are used in this topic are defined as follows:
●Stroke volume is the amount of blood pumped with each beat. It is influenced by preload, afterload, and contractility. (See "Pathophysiology of heart failure: Left ventricular pressure-volume and other hemodynamic relationships", section on 'Normal left ventricular pressure-volume relationship'.)
- Andersen HR, Falk E, Nielsen D. Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am Coll Cardiol 1987; 10:1223.
- Goldstein JA. Pathophysiology and management of right heart ischemia. J Am Coll Cardiol 2002; 40:841.
- Isner JM, Roberts WC. Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease. Frequency, location, associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction. Am J Cardiol 1978; 42:885.
- Isner JM. Right ventricular myocardial infarction. JAMA 1988; 259:712.
- Cabin HS, Clubb KS, Wackers FJ, Zaret BL. Right ventricular myocardial infarction with anterior wall left ventricular infarction: an autopsy study. Am Heart J 1987; 113:16.
- Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med 1994; 330:1211.
- Berger PB, Ruocco NA Jr, Ryan TJ, et al. Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thrombolytic therapy (results from the thrombolysis in myocardial infarction [TIMI] II trial). The TIMI Research Group. Am J Cardiol 1993; 71:1148.
- Sakata K, Yoshino H, Kurihara H, et al. Prognostic significance of persistent right ventricular dysfunction as assessed by radionuclide angiocardiography in patients with inferior wall acute myocardial infarction. Am J Cardiol 2000; 85:939.
- Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993; 328:981.
- Bush LR, Buja LM, Samowitz W, et al. Recovery of left ventricular segmental function after long-term reperfusion following temporary coronary occlusion in conscious dogs. Comparison of 2- and 4-hour occlusions. Circ Res 1983; 53:248.
- O'Neill W, Timmis GC, Bourdillon PD, et al. A prospective randomized clinical trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial infarction. N Engl J Med 1986; 314:812.
- Bowers TR, O'Neill WW, Grines C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998; 338:933.
- Dell'Italia LJ, Lembo NJ, Starling MR, et al. Hemodynamically important right ventricular infarction: follow-up evaluation of right ventricular systolic function at rest and during exercise with radionuclide ventriculography and respiratory gas exchange. Circulation 1987; 75:996.
- Lim ST, Marcovitz P, Pica M, et al. Right ventricular performance at rest and during stress with chronic proximal occlusion of the right coronary artery. Am J Cardiol 2003; 92:1203.
- Kusachi S, Nishiyama O, Yasuhara K, et al. Right and left ventricular oxygen metabolism in open-chest dogs. Am J Physiol 1982; 243:H761.
- Lee FA. Hemodynamics of the right ventricle in normal and disease states. Cardiol Clin 1992; 10:59.
- Hess DS, Bache RJ. Transmural right ventricular myocardial blood flow during systole in the awake dog. Circ Res 1979; 45:88.
- Haupt HM, Hutchins GM, Moore GW. Right ventricular infarction: role of the moderator band artery in determining infarct size. Circulation 1983; 67:1268.
- Shiraki H, Yoshikawa T, Anzai T, et al. Association between preinfarction angina and a lower risk of right ventricular infarction. N Engl J Med 1998; 338:941.
- Zeymer U, Neuhaus KL, Wegscheider K, et al. Effects of thrombolytic therapy in acute inferior myocardial infarction with or without right ventricular involvement. HIT-4 Trial Group. Hirudin for Improvement of Thrombolysis. J Am Coll Cardiol 1998; 32:876.
- Goldstein JA, Barzilai B, Rosamond TL, et al. Determinants of hemodynamic compromise with severe right ventricular infarction. Circulation 1990; 82:359.
- Kakouros N, Cokkinos DV. Right ventricular myocardial infarction: pathophysiology, diagnosis, and management. Postgrad Med J 2010; 86:719.
- Bowers TR, O'Neill WW, Pica M, Goldstein JA. Patterns of coronary compromise resulting in acute right ventricular ischemic dysfunction. Circulation 2002; 106:1104.
- Goldstein JA, Tweddell JS, Barzilai B, et al. Right atrial ischemia exacerbates hemodynamic compromise associated with experimental right ventricular dysfunction. J Am Coll Cardiol 1991; 18:1564.
- Moore CA, Nygaard TW, Kaiser DL, et al. Postinfarction ventricular septal rupture: the importance of location of infarction and right ventricular function in determining survival. Circulation 1986; 74:45.
- Braat SH, de Zwaan C, Brugada P, et al. Right ventricular involvement with acute inferior wall myocardial infarction identifies high risk of developing atrioventricular nodal conduction disturbances. Am Heart J 1984; 107:1183.
- Strasberg B, Pinchas A, Arditti A, et al. Left and right ventricular function in inferior acute myocardial infarction and significance of advanced atrioventricular block. Am J Cardiol 1984; 54:985.
- Mavrić Z, Zaputović L, Matana A, et al. Prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and without right ventricular involvement. Am Heart J 1990; 119:823.
- Goldstein JA, Lee DT, Pica MC, et al. Patterns of coronary compromise leading to bradyarrhythmias and hypotension in inferior myocardial infarction. Coron Artery Dis 2005; 16:265.
- Ricci JM, Dukkipati SR, Pica MC, et al. Malignant ventricular arrhythmias in patients with acute right ventricular infarction undergoing mechanical reperfusion. Am J Cardiol 2009; 104:1678.
- Braat SH, Brugada P, de Zwaan C, et al. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49:368.
- Candell-Riera J, Figueras J, Valle V, et al. Right ventricular infarction: relationships between ST segment elevation in V4R and hemodynamic, scintigraphic, and echocardiographic findings in patients with acute inferior myocardial infarction. Am Heart J 1981; 101:281.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Robalino BD, Whitlow PL, Underwood DA, Salcedo EE. Electrocardiographic manifestations of right ventricular infarction. Am Heart J 1989; 118:138.
- Braat SH, Brugada P, De Zwaan C, et al. Right and left ventricular ejection fraction in acute inferior wall infarction with or without ST segment elevation in lead V4R. J Am Coll Cardiol 1984; 4:940.
- Braat SH, Gorgels AP, Bär FW, Wellens HJ. Value of the ST-T segment in lead V4R in inferior wall acute myocardial infarction to predict the site of coronary arterial occlusion. Am J Cardiol 1988; 62:140.
- Wellens HJ. The value of the right precordial leads of the electrocardiogram. N Engl J Med 1999; 340:381.
- Saw J, Davies C, Fung A, et al. Value of ST elevation in lead III greater than lead II in inferior wall acute myocardial infarction for predicting in-hospital mortality and diagnosing right ventricular infarction. Am J Cardiol 2001; 87:448.
- www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007). www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- Kahn JK, Bernstein M, Bengtson JR. Isolated right ventricular myocardial infarction. Ann Intern Med 1993; 118:708.
- Goldberger JJ, Himelman RB, Wolfe CL, Schiller NB. Right ventricular infarction: recognition and assessment of its hemodynamic significance by two-dimensional echocardiography. J Am Soc Echocardiogr 1991; 4:140.
- D'Arcy B, Nanda NC. Two-dimensional echocardiographic features of right ventricular infarction. Circulation 1982; 65:167.
- Jugdutt BI. Right Ventricular Infarction: Contribution of Echocardiography to Diagnosis and Management. Echocardiography 1999; 16:297.
- Dokainish H, Abbey H, Gin K, et al. Usefulness of tissue Doppler imaging in the diagnosis and prognosis of acute right ventricular infarction with inferior wall acute left ventricular infarction. Am J Cardiol 2005; 95:1039.
- Kakouros N, Kakouros S, Lekakis J, et al. Tissue Doppler imaging of the tricuspid annulus and myocardial performance index in the evaluation of right ventricular involvement in the acute and late phase of a first inferior myocardial infarction. Echocardiography 2011; 28:311.
- Dell'Italia LJ, Starling MR, Crawford MH, et al. Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. J Am Coll Cardiol 1984; 4:931.
- Cohn JN, Guiha NH, Broder MI, Limas CJ. Right ventricular infarction. Clinical and hemodynamic features. Am J Cardiol 1974; 33:209.
- Kumar A, Abdel-Aty H, Kriedemann I, et al. Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction. J Am Coll Cardiol 2006; 48:1969.
- Grothoff M, Elpert C, Hoffmann J, et al. Right ventricular injury in ST-elevation myocardial infarction: risk stratification by visualization of wall motion, edema, and delayed-enhancement cardiac magnetic resonance. Circ Cardiovasc Imaging 2012; 5:60.
- McConnell MV, Solomon SD, Rayan ME, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996; 78:469.
- Casazza F, Bongarzoni A, Capozi A, Agostoni O. Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr 2005; 6:11.
- Ferrario M, Poli A, Previtali M, et al. Hemodynamics of volume loading compared with dobutamine in severe right ventricular infarction. Am J Cardiol 1994; 74:329.
- Goodfellow J, Walker PR. Reversal of atropine-resistant atrioventricular block with intravenous aminophylline in the early phase of inferior wall acute myocardial infarction following treatment with streptokinase. Eur Heart J 1995; 16:862.
- Topol EJ, Goldschlager N, Ports TA, et al. Hemodynamic benefit of atrial pacing in right ventricular myocardial infarction. Ann Intern Med 1982; 96:594.
- Müllner M, Urbanek B, Havel C, et al. Vasopressors for shock. Cochrane Database Syst Rev 2004; :CD003709.
- Weiss S, Jolly N, Shah AP. Multivessel intervention and placement of a percutaneous right ventricular assist device in a patient with acute myocardial infarction complicated by cardiac arrest. J Invasive Cardiol 2011; 23:248.
- Arrieta-Garcia C, Klein LW. Right ventricular assist devices in right ventricular infarction: do they augment right ventricular function sufficiently to improve prognosis? J Invasive Cardiol 2011; 23:252.
- Margey R, Chamakura S, Siddiqi S, et al. First experience with implantation of a percutaneous right ventricular Impella right side percutaneous support device as a bridge to recovery in acute right ventricular infarction complicated by cardiogenic shock in the United States. Circ Cardiovasc Interv 2013; 6:e37.
- Anderson MB, Goldstein J, Milano C, et al. Benefits of a novel percutaneous ventricular assist device for right heart failure: The prospective RECOVER RIGHT study of the Impella RP device. J Heart Lung Transplant 2015; 34:1549.
- Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008; 29:2909.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110:588.
- Bueno H, López-Palop R, Bermejo J, et al. In-hospital outcome of elderly patients with acute inferior myocardial infarction and right ventricular involvement. Circulation 1997; 96:436.
- Mehta SR, Eikelboom JW, Natarajan MK, et al. Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiol 2001; 37:37.
- Gumina RJ, Wright RS, Kopecky SL, et al. Strong predictive value of TIMI risk score analysis for in-hospital and long-term survival of patients with right ventricular infarction. Eur Heart J 2002; 23:1678.
- Jacobs AK, Leopold JA, Bates E, et al. Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry. J Am Coll Cardiol 2003; 41:1273.
- Brodie BR, Stuckey TD, Hansen C, et al. Comparison of late survival in patients with cardiogenic shock due to right ventricular infarction versus left ventricular pump failure following primary percutaneous coronary intervention for ST-elevation acute myocardial infarction. Am J Cardiol 2007; 99:431.
- Larose E, Ganz P, Reynolds HG, et al. Right ventricular dysfunction assessed by cardiovascular magnetic resonance imaging predicts poor prognosis late after myocardial infarction. J Am Coll Cardiol 2007; 49:855.
- BASIC CONCEPTS
- Right ventricular infarction versus ischemia
- Site of the culprit lesion
- Hemodynamic consequences
- Electrical consequences
- CLINICAL PRESENTATION
- History and physical examination
- Electrocardiographic features
- Hemodynamic monitoring
- Other imaging studies
- DIFFERENTIAL DIAGNOSIS
- Optimization of right ventricular preload
- Optimization of right ventricular afterload
- Optimization of heart rate and AV synchrony
- Inotropic drugs
- Coronary reperfusion
- Mechanical assist devices
- Antiischemic drug therapy
- Recommendations of others
- Early prognosis
- Long-term prognosis
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS