CHF pt's

[Camulos]

Exactly, this is associated with isolated RVI; however, isolated RVI is in fact quite rare.

True indeed. Perhaps not as rare as the second article reports though. In this article it states ;

"The previously reported incidence of isolated RVI is very low (< 0.5% of all myocardial infarctions).4."

If I have read the reference list correctly, this < 0.5 % incidence of isolated RVI comes from a 1992 study. This low figure, at the time this article was published, was possibly due to the fact that isolated RVI may have not been recognised - not because it was not occurring. Although RVI was first postulated in the late 40's it still didn't really gain much kudos until the late 90's. Some might argue it has still not gained worthy recognition as a significant clinical entity. I, with others, published an article in 2002 on isolated RVI. In quite an exhausting literature search we found the incidence anywhere within the range of <1% to around 10% of all MI's. So perhaps it is more common than once thought - and the reasons for this are multifactorial.

Regardless of how prevalent isolated RVI is I believe the important point to note is that it is crucial to recognise when it DOES occur - so that <1 - 10% of the time. Standard MI treatment, assuming LVI, can be quite detrimental to a pt suffering isolated RVI. As a standard, I strongly believe that any inferior changes on an 12 lead ECG should mandate a right sided ECG paying particular attention to V3R and V4R.

Also in the second article I noticed this statement;

"However, the incidence could be underestimated and the increasing application of primary PCI as a reperfusion strategy in acute myocardial infarction will likely result in a higher actual incidence of this infarct location."

I don't understand how primary PCI increases the INCIDENCE of isolated RVI. I can understand how it may increase the RECOGNITION of isolated RVI however maybe I am missing something. Can someone please enlighten me? :?

So I guess my message when dealing with isolated RVI - GET IT RIGHT!!!!

Stay safe,

Curse :evil:

[chbare]

Regardless of how prevalent isolated RVI is I believe the important point to note is that it is crucial to recognise when it DOES occur - so that <1 - 10% of the time. Standard MI treatment, assuming LVI, can be quite detrimental to a pt suffering isolated RVI. As a standard, I strongly believe that any inferior changes on an 12 lead ECG should mandate a right sided ECG paying particular attention to V3R and V4R.

Curse :evil:

Absolutely agree. I think some of these concepts have been confused and taken out of context. While, elevation of your V leads can occur with isolated RVI, like you, I still think V4R is still one of the standards when attempting to look for RVI using XII lead evidence.

I suspect the RVI problem associated with PCI is related to inadvertent occlusion of vessels down stream during the procedure. This may also be related to right versus left coronary artery dominance and the said procedure.

Take care,

chbare.

[Camulos]

I suspect the RVI problem associated with PCI is related to inadvertent occlusion of vessels down stream during the procedure. This may also be related to right versus left coronary artery dominance and the said procedure.

So it's those damn interventional cardiologists doing it!!! :roll: Good to see they are raising the profile of isolated RVI by increasing its incidence.

Stay safe,

Curse :evil:

[chbare]

As a nurse, it sure is fun to blame to woes of western society on physicians; however, I could be off on my assessment.

I found a case review from 2003 from New England Journal of Medicine:

A 47-year-old man with no history of cardiac disease presented to a hospital, reporting severe substernal chest pressure associated with bilateral arm weakness. A standard 12-lead electrocardiogram (Panel A) showed marked ST-segment elevation in leads V1, V2, and V3 and slight ST-segment elevation in leads II, III, and aVF. The patient was treated with fibrinolytic therapy and transferred to another hospital for catheterization. Angiography showed severe proximal stenosis of a small, nondominant right coronary artery and no clinically significant disease in the left coronary artery. Contrast-enhanced magnetic resonance imaging 48 hours after presentation (Panel showed delayed hyperenhancement of the right ventricular (RV) free wall (arrowheads) and sparing of the left ventricle (LV) and the right ventricular apex — observations consistent with the presence of isolated right ventricular infarction.

Isolated right ventricular infarction is uncommon and accounts for less than 3 percent of cases of myocardial infarction with acute ST-segment elevation. The electrocardiographic changes may be misinterpreted as signs of infarction of the anterior wall because of the ST-segment elevation in leads V1 and V2. Our patient did not have the typical hemodynamic abnormalities associated with severe right ventricular infarction, probably because of isolated infarction of the right ventricular free wall with sparing of the apex. The patient was discharged in good condition.

Finn and Antman 349 (17): 1636, Figure 1 October 23, 2003

Again, we have the changes in our V leads and even subtle changes in our inferior leads. However, we are not talking about the relationship between inferior wall MI and RVI. Again, these changes appear to be associated with isolated RVI.

Take care,

chbare.

[Camulos]

Again, we have the changes in our V leads and even subtle changes in our inferior leads. However, we are not talking about the relationship between inferior wall MI and RVI. Again, these changes appear to be associated with isolated RVI.

Interesting case. And highlights the reason why I stated earlier that ANY changes in the inferior leads mandates a right sided ECG. Hell let's do one on everybody at triage regardless of what they present with. Sore finger = R sided ECG, headache = R sided ECG, visiting a relative = R sided ECG. I'm joking of course. But it is important to remember to do one when ANY anomalies appear in the inferior leads.

Stay safe,

Curse :evil:

[Mateo_1387]

So are they any available 12 leads with inferior ST segment changes that also have ST segment changes in V4?

[chbare]

Actually, many exist. Reciprocal changes in the V leads are not uncommon in the presence of inferior wall MI. ST segment changes in the V leads should also increase your index of suspicion for posterior wall infract as well. In fact, some people talk about doing a mirror test to ID posterior wall infarct with ST depression in the V leads. However, I prefer to simply look at the posterior leads.

Take care,

chbare.