Diagnosis Of Right Ventricular Infarction Research Articles

Assessment of ECG Criteria for the Diagnosis of Right Ventricular Infarction

Assessment of ECG Criteria for the Diagnosis of Right Ventricular Infarction

Diagnostic value of standard electrocardiogram in acute right ventricular myocardial infarction.

Myocardial infarction (MI) (i.e., heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia) which accounts for a large number of deaths in the hospital. Diagnosis of myocardial infarction is confirmed based on clinical manifestations and electrocardiographic changes along with increased cardiac enzymes. Electrocardiogram (ECG) is one of the safest and easiest methods in the first place. Therefore, this study aimed to investigate the diagnostic value of standard electrocardiogram in the diagnosis of acute right ventricular infarction following lower cardiac infarction. This research was carried out at a time interval of one and a half years to diagnose acute primary infarction. In this method, the diagnostic value of ST↓ in lead I, ST↓ in lead aVL and I ST↓ + aVL, compared with ST↑ in lead V4R was investigated for diagnosis of right ventricular infarction. ST↑ in the lead V4R is a gold standard for the detection of right ventricular MI. All the patients who had the inclusion criteria were allowed to participate in the study. A total of 66 patients participated in the study. Accordingly, 58 (87%) were male and 8 (13%) were female. The mean age of the population was 54.9 ± 11.41. According to the ST↑ standard in lead V4R, 26 patients (39%) had right ventricular myocardial infarction. There was no significant relationship between angina pectoris and premature infarction (P-Value = 0.869). In this study, the right ventricular was most commonly involved in right coronary artery (78%). There was no significant relationship between the occlusion of right coronary artery and right ventricular infarction in 60 patients (P-Value = 0.94). The results showed that electrocardiogram manifestations help determine the occlusion site and the area at risk (ST↓ in lead aVL and aVL + I, sensitivity = 96%). In myocardial infarction, symptoms such as the ST-Segment elevation in lead aVR and ST-Segment depression in the lower leads are possible. Accordingly, in the lower infarction, ST changes in the leads V1-V6 are helpful in detecting patients at risk. Thus, the use of electrocardiogram in acute myocardial infarction helps detect more invasive patients and prevents extensive myocardial damage and other complications.

In inferior myocardial infarction, neither ST elevation in lead V1 nor ST depression in lead I are reliable findings for the diagnosis of right ventricular infarction

ObjectiveIn the presence of inferior myocardial infarction (MI), ST depression (STD) in lead I has been claimed to be accurate for diagnosis of right ventricular (RV) MI. We sought to evaluate this claim and also whether ST Elevation (STE) in lead V1 would be helpful, with or without STD in V2. MethodsRetrospective study of consecutive inferior STEMI, comparing ECGs of patients with, to those without, RVMI, as determined by angiographic coronary occlusion proximal to the RV marginal branch. STE and STD were measured at the J-point, relative to the PQ junction. The primary outcomes were sensitivity/specificity of 1) STD in lead I ≥ 0.5 mm and 2) STE in lead V1 ≥ 0.5 mm, stratified by presence or absence of posterior (inferobasal) MI, as determined by ≥0.5 mm STD in lead V2, for differentiating RVMI from non-RVMI. ResultsOf 149 patients with inferior STEMI, 43 (29%) had RVMI and 106 (71%) did not. There was no difference in the presence or absence of at least 0.5 mm STD in Lead I between patients with (37/43, 86%) vs. without RVMI (85/106, 80%, p = 0.56). In those with, vs. without, RVMI, (15/43, 35%) had STE in V1, versus (17/106, 16%) (p = 0.015). Specificity of STE in V1 for RVMI was 84%; sensitivity was 35%. Sensitivity was higher without (69%), than with (35%), STD in V2. ConclusionAmong inferior STEMI, the presence of any ST depression in lead I does not help to diagnose RVMI. ST elevation ≥0.5 mm in lead V1 is specific for RVMI, and moderately sensitive only if concomitant STD ≥ 0.5 mm in V2 is not present. Although STE in V1 is quite specific, overall the diagnostic characteristics of the standard 12‑lead ECG are inadequate to definitively diagnose, or exclude, RVMI, as defined angiographically.

Right Ventricular Infarction in Inferior Wall Myocardial Infarction

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.

Women have right ventricular infarction more frequently than men

Objective The objective of the study was to determine whether women signifi cantly have more frequently right ventricular infarction than men.Methods The study population consisted of consecutive patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous intervention. The following criteria were used for the diagnosis of right ventricular infarction: ST-segment elevation in one of the right precordial leads V4R-V6R for equal or more than 1 mm together with ST-segment elevation in at least two contiguous inferior leads. The odds ratio for the diagnosis was calculated according to gender. Searching PubMed, nine more relevant studies that used the same criteria for the diagnosis of right ventricular infarction were identifi ed and a meta-analysis was conducted.Results In our group of 517 consecutive patients with STEMI, 32 (23.5%) of 136 women and 42 (11.0%) of 381 men had RVI (odds ratio (OR) = 2.48, 95% confi dence interval (CI): 1.49-4.13; P= 0.001). Two hundred and seventy-fi ve patients had inferior STEMI and among them 32 (42.7%) of 75 women and 42 (23.1%) of 182 men, had a right ventricular infarction (OR = 2.48, 95%CI: 1.40-4.40; P= 0.002). In a meta-analysis, a total number of 4,326 patients with inferior STEMI were included. Four hundred and thirty-seven (41.4%) out of 1,056 women and 1,221 (37.3%) out of 3,270 men, had been diagnosed with RVI (OR = 1.27, 95%CI: 1.09 - 1.48; P= 0.021).Conclusion Right ventricular infarctions occur more frequently in women than in men.

Utility of cardiac magnetic resonance (CMR) in the evaluation of right ventricular (RV) involvement in patients with myocardial infarction (MI)

The aim of this work was to compare the prevalence of right ventricle involvement in a population of patients with myocardial infarction as detected by cardiac magnetic resonance (CMR), clinical presentation, electrocardiographic (ECG) and echocardiographic criteria. A total of 97 consecutive patients, admitted to our institution for acute myocardial infarction, underwent a standard CMR examination within 5days after the event. The presence of myocardial oedema and late enhancement of the right ventricle were compared to infarct location (anterior vs. inferior), clinical data, ECG, echocardiography results and other CMR findings. The results were analysed statistically using the Student's t test for independent samples and the K statistic. Among the 97 patients included in the study, a diagnosis of right ventricular infarction was established in 12, 14 and 24 cases on the basis of the clinical data, the ECG and echocardiography, respectively. CMR demonstrated myocardial oedema and late enhancement of the right ventricle in 48 and 32 cases, respectively. The right ventricle was involved in 46% of patients with inferior myocardial infarction (15/32) and in 30% with anterior myocardial infarction (17/56), correlating to a worsening of both right and left ventricular performance (p=0.001-0.05). The right ventricle is frequently involved in myocardial infarction, correlating to a worse functional impairment of both ventricles and a worse prognosis. This finding, which is often underestimated by traditional cardiological tests, is well revealed by CMR, with potential clinical and therapeutic impact.

Acute coronary syndrome, right ventricular dysfunction and cardiogenic shock: A diagnostic challenge

Right ventricular infarction is uncommon in isolation but can be observed in 50% of cases of inferior wall myocardial infarction. Diagnosis is difficult and suspicion of this condition should always be borne in mind. Progression to cardiogenic shock is not uncommon, when the outcome is similar to left ventricular infarction; mortality can reach 60%. We present the case of a 64-year-old woman with known coronary disease who was admitted to our coronary care unit after an anterior myocardial infarction. Cardiac catheterization showed diffuse stenosis of the left descending and 70% stenosis of the posterior descending arteries. She was surgically revascularized with a favorable evolution, but was later readmitted for acute decompensated heart failure with cardiogenic shock. She was refractory to medical therapy, with biventricular dysfunction on echocardiographic examination. Cardiac magnetic resonance imaging confirmed the diagnosis of right ventricular infarction.

Acute coronary syndrome, right ventricular dysfunction and cardiogenic shock: A diagnostic challenge

Right ventricular infarction is uncommon in isolation but can be observed in 50% of cases of inferior wall myocardial infarction. Diagnosis is difficult and suspicion of this condition should always be borne in mind. Progression to cardiogenic shock is not uncommon, when the outcome is similar to left ventricular infarction; mortality can reach 60%. We present the case of a 64-year-old woman with known coronary disease who was admitted to our coronary care unit after an anterior myocardial infarction. Cardiac catheterization showed diffuse stenosis of the left descending and 70% stenosis of the posterior descending arteries. She was surgically revascularized with a favorable evolution, but was later readmitted for acute decompensated heart failure with cardiogenic shock. She was refractory to medical therapy, with biventricular dysfunction on echocardiographic examination. Cardiac magnetic resonance imaging confirmed the diagnosis of right ventricular infarction.

Isolated right ventricular infarction during percutaneous coronary intervention

Isolated right ventricular infarction (RVI) is an increasingly recognized cause of precordial ST-segment elevation (STE). A patient is described who developed STE in leads V1-V5 secondary to occlusion of the right ventricular branch during stent angioplasty to the right coronary artery. The pattern of precordial STE was thought to be suggestive of anteroseptal myocardial infarction because of progressive STE toward lead V3. Repeat angiography disclosed a patent left anterior descending artery. Subsequent scrutiny of the electrocardiogram (ECG) revealed that leads V2 and V3 were switched and ECG interpretation considering this technical error revealed STE in V2>V3, which favored RVI. Furthermore, the mean spatial ST vector was approximately +120° in the frontal plane producing ST-segment depression in leadI which argued against anteroseptal myocardial infarction and indicated right ventricular epicardial injury. This report highlights that analysis of the ECG using vector concepts is a useful adjunct to pattern recognition for the diagnosis of RVI.

Tricuspid Annular Velocity Assessed by Doppler Tissue Imaging as a Marker of Right Ventricular Involvement in the Acute and Late Phase after a First ST Elevation Myocardial Infarction

Right ventricular (RV) involvement in patients with ST elevation myocardial infarction (STEMI) is a clinically important problem. The aim of this study was to evaluate the use of tricuspid annular velocity assessed by Doppler tissue imaging (DTI) as a marker of RV involvement in patients with a first STEMI. Seventy-one patients with a first STEMI were examined by echocardiography before discharge and after 6 months. The patients were compared to 31 healthy subjects (HS). The diagnosis of RV infarction was based on the presence of >or= 1 mm ST elevation in the right precordial ECG lead V4R. Tricuspid annular systolic and diastolic velocities using pulsed-wave DTI were recorded at the RV free wall. At day 1, tricuspid annular velocities were significantly reduced in patients with, compared to those without, ST elevation in V4R (11.1 vs. 13.7 cm/sec, 9.4 vs. 13.1 cm/sec and 14.1 vs. 15.9 cm/sec for systolic, early, and late diastolic velocities, respectively; P < 0.01). With a cutoff value for a tricuspid annular systolic velocity of 13 cm/sec, sensitivity and specificity for identifying patients with ST elevation in V4R were 89% and 71%, respectively. After 6 months, both tricuspid annular systolic and diastolic velocities in patients with RV infarction had increased significantly, but only tricuspid annular systolic velocity was still reduced compared to HS (12.3 vs. 14.7 cm/sec; P < 0.01). Tricuspid annular velocities assessed by DTI may be used as a marker of RV involvement in the acute and the late phase after a first STEMI.

Accurate diagnosis of right ventricular infarction

Effective treatment for acute myocardial infarction (AMI) is dependent on accurate' diagnoses of the site of infarction. Left ventricular myocardial infarction (LVMI) is the most common form of infarction, of which inferior is the most common site. Patients who have experienced inferior infarctions have a better survival rate than those who have experienced AMIs at other sites. Around one quarter of AMIs affect the right ventricle, and the risk of morbidity for patients who have experienced right ventricular myocardial infarctions is greater than that for patients who have experienced LVMIs. Some authors suggest this is because right-sided heart dysfunction is rarely assessed in standard electrocardiography (ECG), and so opportunities for accurate diagnoses are missed. This article describes how non-standard precordial ECG lead placement can increase the likelihood of diagnosis and therefore improve patient outcomes.

1046 Diagnosis of right ventricular infarction in patients with proximal right coronary artery lesion - diagnostic significance of pulsed Doppler Tissue Imaging

1046 Diagnosis of right ventricular infarction in patients with proximal right coronary artery lesion - diagnostic significance of pulsed Doppler Tissue Imaging

Contrast-Enhanced Cardiovascular Magnetic Resonance Imaging of Right Ventricular Infarction

We assessed the role of late enhancement cardiovascular magnetic resonance imaging (LE-CMR) for the diagnosis of right ventricular infarction (RVI). Right ventricular infarction occurs in about one-half of patients with inferior myocardial infarction (MI). It is associated with an unfavorable prognosis, but established methods often lack the diagnostic accuracy to detect it. Late enhancement cardiovascular magnetic resonance imaging accurately detects left ventricular MI. Thirty-seven patients with acute inferior MI were included. To test for RVI, they prospectively underwent a physical examination, an electrocardiogram (ECG) for ST-segment elevation in the V4r right precordial lead, and an echocardiogram. After coronary reperfusion, LE-CMR was performed for assessing presence and extent of late enhancement in the right ventricular (RV) wall. The LE-CMR data were compared with the other results; interobserver variability was assessed. The LE-CMR was repeated after 13 months. Late enhancement cardiovascular magnetic resonance imaging detected RVI in 21 of 37 (57%) patients with acute inferior MI. Interobserver variability was very good (kappa 0.83); physical exam was positive for RVI in 7 of 37 (19%) patients, V4r ECG in 13 of 37 (35%) patients, and echocardiogram in 6 of 37 (16%) patients. The LE-CMR findings for RVI showed only mild agreement with findings for RVI on physical exam (kappa 0.30), V(4)r ECG (kappa 0.38), and echocardiography (kappa 0.32). Irreversible injury of the RV persisted at 13 months (kappa 0.85). In patients with acute inferior MI, RVI is more frequently detected by LE-CMR than by current standard diagnostic techniques. Further CMR studies might allow for analyzing its clinical and prognostic relevance.

Colour Tissue Doppler Echocardiographic Evaluation of Right Ventricular Function in Patients with Right Ventricular Infarction

Objective: This study was undertaken to determine right ventricular (RV) function as assessed by colour Doppler tissue imaging (DTI) in patients with RV infarction. Methods: During the study period, 35 patients were evaluated: 14 patients had an inferior myocardial infarction (MI) with RV infarction and 21 patients had an inferior MI without RV involvement. Twenty age-matched healthy subjects served as controls. The diagnosis of RV infarction was defined by ST segment elevation >0.1 mV in lead V4R. Systolic and early and late diastolic velocities were acquired from the apical four-chamber view at the lateral tricuspid annulus, the septal side of the tricuspid annulus and the RV free mid-wall using colour DTI. Results: Systolic and early diastolic velocities at the lateral tricuspid annulus were significantly reduced in patients with inferior MI with RV infarction compared with those in healthy individuals (7.8 ± 1 vs. 11 ± 2 cm/s, p < 0.002) and patients with inferior MI without RV infarction (7.8 ± 1 vs. 10 ± 1 cm/s, p < 0.002). The late diastolic lateral annular velocity did not differ between the groups. Systolic and early diastolic RV free wall velocities were also significantly decreased in patients with RV infarction compared with those in healthy individuals (7 ± 1 vs. 8.7 ± 1 cm/s, p < 0.01; 6.3 ± 2 vs. 8.7 ± 2 cm/s, p < 0.05, respectively) and patients with inferior MI without RV infarction (7 ± 1 vs. 9 ± 2 cm/s, p < 0.01; 6.3 ± 2 vs. 8.3 ± 2 cm/s, p < 0.05, respectively). Conclusion: The evaluation of tricuspid annular and RV free wall velocities using colour DTI provides a rapid and noninvasive tool for assessing RV function in patients with RV infarction.

Electrocardiographic manifestations: right ventricular infarction

The 12-lead electrocardiogram (EKG) is an essential tool when evaluating the Emergency Department (ED) patient with suspected cardiac ischemia. The standard EKG has limitations when evaluating “remote” areas of the heart such as the left posterior wall or right ventricular wall. Diagnosis of right ventricular infarction (RVI) in the presence of acute inferior wall myocardial infarction (MI) is made utilizing right-sided chest leads with high sensitivities and specificities. RVI is a serious ED problem because morbidity and mortality is higher in acute MIs associated with RVI.

Doppler echocardiographic evaluation of right ventricular function in patients with right ventricular infarction.

The aim of the present study was to assess the utility of the myocardial performance index in patients with right ventricular infarction. During the study period, 120 patients were evaluated: 50 patients had a right ventricular infarction and 70 patients had an inferior left ventricular infarction without right ventricular involvement. On admission, an echocardiogram was obtained from all patients prior to the initiation of thrombolytic therapy. The right ventricular myocardial performance index was calculated, as were the Doppler-derived parameters of the right side of the heart. All patients with right ventricular infarction had undergone a right ventricular dilation, compared with 70 patients with left ventricular infarction (right ventricular end diastolic diameter 32 +/- 13 versus 26 +/- 24 mm; P < 0.01) and increased areas (diastolic area 24.8 +/- 9.9 versus 15.1 +/- 6.8 cm2; P < 0.01). Tricuspid regurgitation was detected in 26 patients. The mean peak velocity of tricuspid regurgitation was 3.8 +/- 0.8 m/s. The Doppler intervals, isovolumetric contraction times (136 +/- 30 versus 49 +/- 11 ms; P < 0.01), and relaxation times (71 +/- 28 versus 37 +/- 9 ms; P < 0.01) were prolonged in patients with right ventricular infarction, whereas the ejection time was significantly reduced (250 +/- 31 versus 330 +/- 26 ms; P < 0.001). The myocardial performance index was significantly increased in patients with right ventricular infarction (0.85 +/- 0.2 versus 0.26 +/- 0.1; P < 0.01). The inferior vena cava collapse was reduced in all patients with right ventricular infarction (35 +/- 20%). The right ventricular myocardial performance index was a useful indicator of right ventricular performance in patients with right ventricular infarction. The use of echocardiographic parameters of the right side of the heart and Doppler echocardiographic parameters of right ventricular function provides a reliable diagnosis of right ventricular infarction.

Radiographic findings of patients with right ventricular infarction: prognostic evaluation

Background: The clinical course of right ventricular infarction and its management differs substantially from the management of left ventricular infarction: early and accurate diagnosis is very important.Methods: The patient population included 204 consecutive patients: 96 had a right ventricular infarction and 108 a left ventricular inferior infarction. A standard chest radiograph was obtained within 10 and 48h of onset of symptoms. The width of the azygos vein and the presence of extravascular lung water were evaluated and compared. The in-hospital and long-term course (6 months follow-up) was determined for all patients.Results: The width of the azygos vein was significantly greater in patients with right ventricular infarction than in patients with inferior ventricular infarction. An increase in azygos vein width was greater than 13mm and showed a diagnostic sensitivity of 90% and a specificity of 94%; the positive predictive value for right ventricular infarction was 94%. A ratio between the azygos vein width and an extravascular lung water score of less than 2 indicated a diagnostic sensitivity of 90% and a specificity of 93%. The positive predictive value for right ventricular infarction was 96%. Patients with right ventricular infarction and an azygos vein width greater than the median (16.59mm) had more hypotension, bradycardia and heart block and a higher mortality than did patients with an azygos vein width smaller than the median.Conclusions: A chest radiograph has been shown to be sensitive and specific for the diagnosis of right ventricular involvement in patients with inferior left ventricular infarction. All patients admitted to Coronary Care Units (CCU) should have access to chest radiography, which should help in the early diagnosis of right ventricular infarction

Electrocardiographic diagnosis of right ventricular infarction: Contribution of right chest leads

Electrocardiographic diagnosis of right ventricular infarction: Contribution of right chest leads

Jugular venous pressure and pulse wave form in the diagnosis of right ventricular infarction

Jugular venous pressure (measured clinically) and pulse wave form (recorded at 100 mm/s) were analysed in 44 cases of first acute myocardial infarction and 10 age-matched controls. Patients were divided into different groups according to site of infarction decided by detailed 2-D echocardiography. Raised jugular venous pressure had high specificity (96.8%) but low sensitivity (39%) in diagnosing right ventricular infarction. Positive Kussmaul's sign had equal specificity but lower sensitivity (26.1%). Rapid ‘y’ descent had high specificity (100%) but low sensitivity (17.3%) in diagnosing right ventricular infarction. Jugular venous pressure and pulse wave form are significantly affected by the magnitude of damage to interventricular septum and left ventricular free wall.

Detection of right ventricular infarction by gadolinium DTPA-enhanced magnetic resonance imaging

We investigated the usefulness of gadolinium-enhanced magnetic resonance (Gd-MR) imaging for diagnosis of right ventricular (RV) infarction in 14 patients with acute inferior infarction. Myocardial perfusion images with thallium 201 and technetium 99m pyrophosphate (dual single-photon emission computed tomography: dual SPECT) and haemodynamic data were obtained on admission. Patients were classified into three groups based on dual SPECT and Gd-MR findings: no accumulation in the right ventricle (negative, Type 1), posterior RV infarction (Type 2) and anterior and posterior RV infarction (Type 3). No patients exhibited the haemodynamic criteria for RV infarction (a mean right atrial pressure above 10 mmHg and a ratio of mean right atrial pressure to pulmonary artery wedge pressure above 0.8). Dual SPECT identified RV infarction in eight patients (three Type 2 and five Type 3, 57% of the total). Gd-MR imaging also identified eight patients (57%) as positive (five Type 2 and three Type 3). Our results showed that Gd-MR imaging was not only useful for diagnosis of RV infarction, but also equal to dual SPECT in sensitivity and specificity, and superior to it as regards acquisition time and assessing the spatial anatomy of heart. In conclusion, Gd-MR imaging is superior to dual SPECT for detection of RV infarction.