CardioMan - Case 2

Case 2:

63-year old woman presented with central chest pain of two hours duration. On examination her blood pressure was 90/60 mm Hg, she had a weak pulse, distended neck veins with elevated jugular venous pressure, normal first and second heart sounds and lung fields were clear on auscultation.

Ragavendra R. Baliga, M.D
Assistant Professor
Division of Cardiology
University Of Michigan

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Question 6 of 17:

The benefit of thrombolysis is minimal when inferior wall MI is complicated by right ventricular ischemia.

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Right ventricular infarction accompanying inferior wall myocardial infarction is associated with a substantially higher mortality (25 to 30%) and thus identifies a high-risk subgroup of patients with inferior myocardial infarction (6%) and should be considered high-priority candidates for reperfusion.

One study reported a 31% in-hospital mortality rate in patients with inferior myocardial infarctions as compared with 6% in patients who had an inferior myocardial infarction without right ventricular involvement.

In right ventricular infarction both thrombolytic therapy and primary coronary angioplasty with subsequent reperfusion have been shown to improve right ventricular ejection fraction (1) and reduce the incidence of complete heart block (1-3).

Patients with left bundle branch block and elevation of ST segment in anterior chest leads derive the most benefit from thrombolytic therapy. The patients with inferior ST-segment elevation in inferior chest leads have much less benefit except for the subgroup associated with right ventricular infarction (ST-elevation in V4R) or anterior-segment depression indicative of a posterior current injury as often occurs with occlusion of large circumflex coronary artery. Patients with ST-segment depression do not benefit from thrombolysis. In non-ST elevation MI thrombolysis has no benefit or can even be harmful.

EKG	Lives saved per thousand by thrombolysis
Left bundle branch block	49
Anterior ST segment elevation	37
Inferior ST segment elevation	8
ST segment depression	-14

Data originally derived from Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994;343:311-322.

References:

1. Braat SH, Ramentol M, Halders S, Wellens HJ. Reperfusion with streptokinase of occluded right coronary artery: effects on early and late right and left venricular ejection fraction. Am Heart J 1987;113:257-260.

2. Schuler G, Hofmann M, Schwarz F et al. Effect of successful thrombolytic therapy on right ventricular function in acute inferior wall myocardial infarction. Am J Cardiol 1984;54:951-957.

3. Moreyra AE, Suh C, Porway MN, Kostis JB. Rapid hemodynamic improvement in right ventricular infarction after coronary angioplasty. Chest 1988;94:197-199.