RV Infarction — EECC MCQ

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ModerateCoronary Artery DiseaseRV InfarctionEECC

A 58-year-old man presents with inferior STEMI. Primary PCI reveals an acutely occluded proximal RCA. During PCI, he develops hypotension (BP 70/40), clear lung fields, elevated JVP, and a right-sided S3. What is the diagnosis?

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Correct answer: E — Right ventricular infarction complicating inferior STEMI — managed with IV fluid resuscitation, avoidance of nitrates and diuretics, and consideration of inotropic support

RV infarction occurs in approximately 30-50% of inferior STEMIs (when the proximal RCA is occluded proximal to the RV marginal branches). The classic triad is: hypotension, clear lung fields (no pulmonary oedema), and elevated JVP. The RV depends on preload more than the LV, making it exquisitely sensitive to volume depletion. Management: (1) IV fluid resuscitation (500-1000 mL 0.9% NaCl boluses) to maintain RV preload; (2) AVOID nitrates, morphine, and diuretics (which reduce preload and worsen hypotension); (3) inotropes (dobutamine) if fluids fail; (4) prompt RCA reperfusion (PCI). Right-sided ECG leads (ST elevation in V4R) confirm the diagnosis. The 2023 ESC ACS Guidelines emphasise that RV involvement should be actively sought in all inferior STEMIs.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes