Acute Right Ventricular Myocardial Infarction Treatment Options and Strategies

Acute right ventricular myocardial infarction (RVMI) requires prompt and specialized medical intervention to improve patient outcomes. The primary treatment approach for RVMI is coronary intervention, particularly percutaneous coronary intervention (PCI), which helps restore blood flow to the affected area of the heart. In cases where PCI is not feasible due to anatomical or clinical factors, coronary artery bypass grafting (CABG) may be considered as an alternative therapy. However, the treatment strategy for right ventricular infarction differs somewhat from that of left ventricular myocardial infarction, due to the unique hemodynamic challenges associated with RVMI.

Managing Hemodynamic Instability in RVMI

One of the hallmark clinical features of acute right ventricular infarction is the tendency to develop hypotension. This is primarily due to the right ventricle's dependence on adequate preload to maintain cardiac output. As such, early and aggressive fluid resuscitation is often a critical component of management. In most cases, intravenous fluid administration of 1–2 liters may be necessary to optimize preload and stabilize blood pressure.

When Fluids Aren't Enough: The Role of Inotropic Support

Choosing the Right Inotropic Agent

If hypotension persists despite adequate fluid resuscitation, the next step typically involves the initiation of inotropic therapy. Dobutamine is often the preferred agent due to its ability to enhance myocardial contractility without significantly increasing oxygen demand. Unlike in left ventricular failure, diuretics should be used cautiously, if at all, since they can reduce preload and further compromise right ventricular function.

Addressing Conduction Abnormalities in RVMI

Right ventricular infarction is frequently associated with conduction system disturbances, especially atrioventricular (AV) block. In cases of significant bradycardia or high-grade AV block, temporary pacemaker insertion may be required to maintain adequate heart rate and hemodynamic stability. This supportive measure is often lifesaving and should be considered early in the management of patients showing signs of electrical instability.