This is an interesting scenario.
"Pure" right ventricular infarction is a rare event. I've seen a few "pure"
posterior AMIs, but never a case quite like this.
The literature tells us:
1. There is no evidence regarding thrombolysis in "pure" RV AMI: it's too
rare a condition
2. Patients with a RV infarction in addition to inferior AMI have a worse
prognosis than those with inferior AMI alone
3. Although RV hypokinesia is commonly seen in acute RV infarction, this
usually recovers spontaneously over time
I suspect that the amount of infarcting muscle is anatomically quite small
(unless the underlying anatomy is abnormal): a situation that some people
would call "end artery infarction". This is an occasion when thrombolysis
might be more effective than primary angioplasty.
However, in the absence of any evidence of infarct progression I suspect
that this patient's prognosis is very good. Therefore the benefit of
thrombolysis is likely to be small, and has to be carefully balanced against
the risks. I would probably thrombolyse him if there were absolutely no risk
factors for haemorrhage (which seems to be the case from the information
provided), but would be very reluctant if he were older, hypertensive, etc.
Regards to the list,
Jonathan Benger.
United Bristol Healthcare Trust.
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Bruce Martin
Sent: 18 April 2004 12:51
To: [log in to unmask]
Subject: Re: thrombolysis question
Pain to presentation time was about 2 hours.
By the way, before any pedants get there before me, right sided leads were
elevated from V2R not V1R as this would equate to V2 on the standard ECG.
Bruce
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Simon Odum
Sent: 17 April 2004 10:08
To: [log in to unmask]
Subject: Re: thrombolysis question
I'd thrombolyse too. I know the evidence is not as convincing for right
sided as it is left sided infarcts.
What was the pain-to-presentation time?
Simon Odum
Associate Specialist
North Bristol ED
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Bruce Martin
Sent: 17 April 2004 09:25
To: [log in to unmask]
Subject: thrombolysis question
60 year old man, previously well attends with classical presentation for
MI.
No haemodynamic compromise. 12 lead ECG shows isolated ST elevation in
V1
and III. No ST depression. No contraindications for lysis.
Right sided chest leads show ST elevation from V1R to V6R. (Not attached
ECGs due to file size but can email these on request)
No problem with thrombolysing posterior infarcts, but in a patient with
seemingly isolated right ventricular infarct with no compromise, what
are
the feelings of the group?
Possible options:
1. thrombolyse anyway as regional infarction
2. Wait to see if ST elevation in 2 consecutive leads develops
3. Treat as ACS/ NSTEMI
4. PTCA - yeah, right. Might win the lottery this weekend too!
5. Other
We thrombolysed by the way.
Bruce Martin
SpR Emergency Medicine
North West Region
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