CLINICAL MANIFESTATIONS OF RIGHT VENTRICULAR INFARCT IN PATIENTS OF INFERIOR WALL MYOCARDIAL INFARCTION.
Keywords: Clinical manifestations, RV infarction, Inferior wall MI.
Inferior wall myocardial infarction accounts for 40% of all myocardial infarctions globally. Generally the mortality rates associated with inferior wall myocardial infarction are 1mm in V4R is taken as diagnostic of right ventricular myocardial infarction9. Poor contractility of RV results in septal push to left ventricle that further impairs ventricular filling. Once right ventricular myocardial infarction is confirmed diuretics and beta blockers must be avoided as they can further cause decrease in BP that can be catastrophic3. Delay in management of inferior wall myocardial infarction especially those with right ventricular infarct was associated with more atrio ventricular blocks10. Percutaneous coronary angioplasty remains the most successful treatment option for inferior wall ST elevation myocardial infarction11.
Right ventricular (RV) infarction complicates 30% to 50% of cases of inferior wall MI8. Patients with RV infarction have higher incidence of cardiogenic shock, complete heart block, RV free wall rupture, cardiac tamponade, pulmonary embolism, and atrial fibrillation, resulting in poor clinical outcomes in patients with Inferior wall MI9,10. Further, there are limited data and studies on Inferior wall MI in our population. Thus, the primary aim of the present study was to evaluate complications, subsequent morbidity and mortality, and effect of thrombolytic therapy in patients with inferior wall MI.
MATERIAL AND METHODS
The study was conducted at Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi. A total of 264 patients with inferior wall myocardial in farction were enrolled (164 male and 100 female patients) out of which 82 (31.0%) had right ventricular infarct; of which 56 (21.2%) were males and 26 (9.8%) were female patients. Data regarding age, gender, clinical presentation specially typical chest pain, decreased level ofconsciousness, hypotension, raised jugular venous pressure and changes in standard 12 lead ECG along with right sided leads were noted. Patients withprevious history of any myocardial infarction, chronic kidney disease and chronic liver disease or hypotension were excluded from the study.
Typical chest pain was defined as central aching chest pain associated with sweating, vomiting, radiation to left arm or jaw for more than 30 mins, decreased consciousness was defined as Glasgow Coma Scale of <10/15, patients with a blood pressure of <90/60 mm Hg or Mean Arterial Pressure of 4cm of water from sternal angle. RV infarct was confirmed by presence of ST segment elevation of >1mm in right sided leads or echocardiographic evidence of right ventricular infarct. Diagnostic criteria for inferior myocardial infarction was typical chest pain, ST segment elevation over than 1mm on two or more than two contiguous leads II, III and aVF, and serially raised Trop I levels. Renal function tests, liver function tests and electrolyte levels were done.
Patients with a previous history of MI or its sequel, Chronic liver disease, chronic kidney disease (eGFR < 60 ml/min/1.73m2) and patients with electrolyte imbalances were excluded from the study. Data was entered and analysed using SPSS 21.0.
###IWMI* with RV* Infarct###IWMI without RV Infarct
Decreased Level Of###16(19.5%)###66###3(1.64%)###179###<0.05
A total of 264 patients of inferior wall myocardial infarction were enrolled for the study. There were 164 (62.1%) male patients and 100 (37.8%) female patients. Mean age of patients was 56.95 +- 8.9, 82 years. 82 (31.0%) patients had RV infarct along with inferior wall myocardial infarction; out of which 56 (21.2%) were males and 26 (9.8%) were female patients. While 182 (968.9%) had inferior wall myocardial infarction with no RV infarction, out of which 108 (40.9%) were males and 74 (28.0%) were females (fig-1). Chest pain, hypotension, raised jugular venous pressure (JVP) and decreased level of consciousness was seen in 79 (96.3%), 51 (62.1%), 18 (21.9%), 16 (19.5%) in patients of IWMI with RV involvement and in 179 (98.3%), 2 (1%), 7 (3.84%), 3 (1.64%) in patients with no RV involvement respectively (fig-2).
This study mainly focused on complications associated with IWMI leading to poor clinical outcomes and worsened prognosis in our study population. In our study we found that the frequency of loss of consciousness, hypotension and raised JVP was more common in those who had RV infarction along with IWMI as compared to those who no RV infarction along with IWMI while frequency of chest pain was more in patients with IWMI with no RV involvement. Khosoosi Niaki compared the clinical manifestations of RV involvement in IWMI and found that the frequency of chest pain, loss of consciousness and hypotension was significantly higher in RV infarct group as compared to IWMI with no RV involvement12. Our results were almost consistent with the findings of Khosoosi Niaki.
In our study we found that symptoms of hypotension, decreased level of consciousness and raised JVP may serve as a clue to the diagnosis of RV infarct in patients of IWMI and therefore right sided chest leads should always be used in such patients presenting with 12 hours of their symptoms. Hemodynamic instability or ST-segment elevation of more than 1 mm in lead V1 raises the suspicion of right ventricular myocardial infarction13,14. AV blocks associated with inferior MI causes a lot of increase in the mortality15. In conclusion chest pain along with loss of consciousness, hypotension and raised JVP are clinically significant markers of RV infarct. Acute RV infarct has almost an equal mortality as compared to LV shock but the management is different as diuretics decrease preload that worsens right heart failure3.
Thus early identification of RV infarct especially the RV leads can help in immediate management steps that can help reduce the increased mortality associated with RV infarct10. Pirzadaemphasized the importance of right sided leads in the diagnosis of RV infarct in patients of inferior wall myocardial infarction. The hypotension in RV infarct with IWMI is attributable to the large size of infarct and decreased contractility of right heart. Hypotension is the most important clinical indicator of RV infarct. Decreased level of consciousness was probably because of decreased perfusion of brain as a result of decreased blood pressures and decreased stroke volume. Raised JVP was attributable to increased pressures in right heart because of decreased contractility of right heart.
The results showed that chest pain, decreased level of consciousness, hypotension, raised JVP were more frequent in inferior MI with RV involvement patients as compared to inferior MI without RV involvement.
CONFLICT OF INTEREST
This study has no conflict of interest to be declared by any author.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Feb 28, 2019|
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