Right Ventricular Infarcts
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Subject:               Right and posterior EKGs...

An excellent review of this subject is alluded to in an emerg med review
booklet that I subscribe to. At Charity, we routinely get a right sided (V4R)
EKG in anyone suspected of having an inferior MI, to identify patients who
are having proximal right coronary artery occlusion with right ventricular
infarct. Posterior EKGs (V9R) we sometimes get for academic purposes if an
echo isn't immediately available and we suspect posterior infarct. Both of
these are regarded around these parts as the "poor man's echo" and give an
inkling of the three dimensional wall motion abnormalities that we suspect
are present during acute infarction.
   According to the referenced article (Chest 107:530;1995), mortality
predictors with IMI are 1) right ventricular infarction, 2) shock, 3) age
>70, 4) withholding of thrombolytics. Of these, the single most powerful
predictor of death is right ventricular infarction, which occurs in 14-80% of
patients with associated left sided infarction.
   A diagnosis of RVI is important because nitrates are usually withheld in
favor of fluid resuscitation, inotropes, and afterload reduction
(specifically with dobutamine, a combination inotrope plus afterload
reducer). Thus, therapy is different than with a simple inferior wall
infarct. Aortic balloon pumps are sometimes used (though we don't have one
handy here), in cases of RVI associated with severe cardiogenic shock.

James Li, MD