Right Ventricular Infarction in Inferior Wall Myocardial Infarction
01 December 2017 (online)
Background Right ventricular infarction (RVI) is common in patients with inferior wall myocardial infarction (IWMI). Right ventricular involvement increases mortality and morbidity in IWMI patients. Clinical presentation of RVI differs, and accordingly treatment and management of patients also differs.
Aim To find out the frequency of RVI among patients with acute IWMI and to determine the utility of clinical examination, electrocardiography (ECG), and echocardiography (ECHO) in the diagnosis of RVI and its severity. Also o study the frequency and complications with reference to sex.
Material and Methods One hundred patients with acute IWMI were recruited. Clinical examination, ECG with right precordial leads, and 2D ECHO (right ventricular end-systolic volume [RVESV] and right ventricular end-diastolic volume [RVEDV], right ventricular stroke volume [RVSV], RVESV index [RVESVI], RVEDV index [RVEDVI], RVSV index [RVSVI], and right ventricular ejection fraction [RVEF]) were done to diagnose RVI and its severity. RVI patients were divided into two groups basing on RVEF as severe RVI (EF < 35%) and mild RVI (EF > 35%).
Results Forty-three (43%) patients had RVI. Thirty-one (72%) patients had mild RVI (EF > 35%) and 12 (28%) had severe RVI (EF < 35%). Clinical examination had less sensitivity (35%) and high specificity (93%) in the diagnosis of RVI whereas it was highly sensitive (100%) and specific (90%) in detecting severe RVI. Total ST elevation of ≥ 3 mm was highly sensitive (92%), and ≥ 5 mm was highly specific (94%) in detecting severe RVI. RVEF (p < 0.01), RVESVI (p < 0.01), RVEDVI (p < 0.01), RVSVI (p < 0.05), and total ST elevation (p < 0.01) were equally effective in detecting severe RVI. Case fatality rate in RVI was 7%. Proportional mortality rate in females was 67%, with higher mortality in females compared with males (p ≤ 0.05).
Conclusion Right-sided leads should be taken in all cases of acute IWMI. Careful clinical examination, total ST elevation in V1, V2, V3R, V4R, ECHO RVESV, RVEDV, RVSV, RVEF, RVESVI, RVEDVI, and RVSVI are useful in detecting severe RVI. Complications were significantly associated with the severity of RVI. Mortality is high in females compared with males.
- 1 Myers GB, Klein HA, Hiratzka T. Correlation of electrocardiographic and pathologic findings in infarction of the interventricular septum and right ventricle. Am Heart J 1949; 37 (05) 720-770
- 2 Levy II L, Hyman AL. Difficulties in the electrocardiographic diagnosis of myocardial infarction. Am Heart J 1950; 39 (02) 243-262
- 3 Wade WG. The pathogenesis of infarction of the right ventricle. Br Heart J 1959; 21 (04) 545-554
- 4 Cohn JN, Guiha NH, Broder MI, Limas CJ. ; Clinical and Hemodynamic Features. Right ventricular infarction. Clinical and hemodynamic features. Am J Cardiol 1974; 33 (02) 209-214
- 5 Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med 1994; 330 (17) 1211-1217
- 6 James TN. Anatomy of the coronary arteries in health and disease. Circulation 1965; 32 (06) 1020-1033
- 7 Gray H, Williams PL, Bannister LH. . In: Williams PL, Dyson M. , ed. Angiology Gray's Anatomy. 38th ed. London: Churchill Livingstone; 1992: 727-731
- 8 Bittl JA, Levin DC. Coronary Arteriography. Braunwald Heart Disease. 5th ed, Volume 1. Eugene Braunwald MD. FRCP ed. Philadelphia, PA: W.B. Saunders; 1997: 247-252
- 9 Mittal SR. Isolated right ventricular infarction. Int J Cardiol 1994; 46 (01) 53-60
- 10 Setaro JF, Cabin HS. Right ventricular infarction. Cardiol Clin 1992; 10 (01) 69-90
- 11 Bean WB. Infarction of the heart II. Clinical course and morphological findings. Ann Intern Med 1938; 12: 71-94
- 12 Dell'Italia LJ, Starling MR, O'Rourke RA. Physical examination for exclusion of hemodynamically important right ventricular infarction. Ann Intern Med 1983; 99 (05) 608-611
- 13 Shantaram V, Kumar DN, Srinath K. Right ventricular infarction. Clinical, ECG and echocardiographic profile. Indian Heart J 1987; 18 (01) 27-30
- 14 Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J 1983; 49 (04) 368-372
- 15 Yoshino H, Udagawa H, Shimizu H. , et al. ST-segment elevation in right precordial leads implies depressed right ventricular function after acute inferior myocardial infarction. Am Heart J 1998; 135 (04) 689-695
- 16 Chou TC, Van der Bel-Kahn J, Allen J, Brockmeier L, Fowler NO. Electrocardiographic diagnosis of right ventricular infarction. Am J Med 1981; 70 (06) 1175-1180
- 17 Klein HO, Tordjman T, Ninio R. , et al. The early recognition of right ventricular infarction: diagnostic accuracy of the electrocardiographic V4R lead. Circulation 1983; 67 (03) 558-565
- 18 Hasche ET, Fernandes C, Freedman SB, Jeremy RW. Relation between ischemia time, infarct size, and left ventricular function in humans. Circulation 1995; 92 (04) 710-719
- 19 Sharpe DN, Botvinick EH, Shames DM. , et al. The noninvasive diagnosis of right ventricular infarction. Circulation 1978; 57 (03) 483-490
- 20 Cohen A, Guyon P, Chauvel C. , et al. Relations between Doppler tracings of pulmonary regurgitation and invasive hemodynamics in acute right ventricular infarction complicating inferior wall left ventricular infarction. Am J Cardiol 1995; 75 (07) 425-430
- 21 Arditti A, Lewin RF, Hellman C, Sclarovsky S, Strasberg B, Agmon J. Right ventricular dysfunction in acute inferoposterior myocardial infarction. An echocardiographic and isotopic study. Chest 1985; 87 (03) 307-314
- 22 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 (04) 823-828
- 23 Pell S, Fayerweather WE. Trends in the incidence of myocardial infarction and in associated mortality and morbidity in a large employed population, 1957–1983. N Engl J Med 1985; 312 (16) 1005-1011