Prevalence and extent of right ventricular dysfunction after myocardial infarction — relation to location and extent of infarction and left ventricular function

doi:10.1016/0167-5273(90)90315-V

International Journal of Cardiology

Volume 28, Issue 3, September 1990, Pages 325-332

https://doi.org/10.1016/0167-5273(90)90315-V Get rights and content

Abstract

In view of today's efforts to preserve myocardial function in acute myocardial infarction, the prevalence and extent of persistent right ventricular dysfunction was analysed in a prospective study of 127 patients admitted with a first myocardial infarction without thrombolysis. Right ventricular ejection fraction measured at hospital discharge by radionuclide angiocardiography was related to the location of infarction as judged electrocardiographically, its size as estimated enzymatically, and by the simultaneously measured left ventricular ejection fraction. Two opposite patterns of right and left ventricular function were observed in relation to the location of infarction: the right ventricular ejection fraction was significantly depressed in inferior, but not in anterior, infarction and the reverse was true for left ventricular ejection fraction (P < 0.001 between infarct locations for both right ventricular ejection fraction and left ventricular ejection fraction). There were significant correlations between peak levels of creatine kinase and left ventricular ejection fraction for anterior (r = 0.76, P < 0.001) and inferior (r = 0.57, P < 0.001) infarction, while peak levels of creatine kinase and right ventricular ejection fraction correlated only in inferior infarction (r = 0.45, P < 0.01). There was no overall correlation for left ventricular ejection fraction and right ventricular ejection fraction (r = 0.28, P NS), despite the fact that right ventricular ejection fraction was lower in patients with severely reduced left ventricular ejection fraction than in those with normal left ventricular function (P < 0.05). Thus, this analysis demonstrates that right ventricular dysfunction after an acute myocardial infarction is much more dependent on the location of infarction and its size than on left ventricular dysfunction. Right ventricular ejection fraction should, therefore, be considered separately in the assessment of myocardial salvage after acute interventions in myocardial infarction.

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Cited by (12)

Right atrial pressure predicts worsening renal function in patients with acute right ventricular myocardial infarction
2018, International Journal of Cardiology
Citation Excerpt :
In patients with inferior myocardial infarction, right ventricular myocardial infarction (RVMI) is associated with a higher number of complications [1,2].
Right ventricular myocardial infarction (RVMI) is associated with serious complications in the short-term. Worsening renal function (WRF) is a frequent and dangerous complication. We investigated if right atrial pressure (RAP) predicts WRF in these patients.
We prospectively studied patients with RVMI. RAP was obtained invasively at admission to coronary care unit. Blood samples were extracted from patients at baseline and every 24 h for creatinine measurements for seven days. We defined WRF as an increase of 25% or 0.5 mg/dl in serum creatinine during the first seven days compared to baseline creatinine.
We included forty-five patients (age 68 ± 10 years, male 71%). WRF occurred in 51%. The best cut-off value of RAP for WRF prediction was 11 mm Hg. RAP ≥ 11 mm Hg was associated with WRF at univariate analysis (OR 5.5, 95% CI 1.27–24.3, p = 0.023) and multivariate analysis (OR 6.1, 95% CI 1.07–35.4, p = 0.042). RAP ≥ 11 mm Hg improved reclassification and discrimination after usual prediction with the Mehran score (net reclassification improvement 64.8%, p = 0.030; integrated discrimination improvement 7.5%, p = 0.037).
In patients with RVMI, RAP ≥ 11 mm Hg predicted WRF and improved discrimination.
Prevention and Treatment of Right Ventricular Failure During Left Ventricular Assist Device Therapy
2018, Critical Care Clinics
Citation Excerpt :
One of the biggest risk factors for postoperative RV failure is preoperative RV dysfunction. Biventricular dysfunction is common in patients with end-stage HFrEF of both ischemic and nonischemic causes and can occur due to the development of chronic secondary pulmonary hypertension (PH), left-sided valvular heart disease, particularly mitral regurgitation (MR), but also due to extension of the primary myopathic process that affects the left ventricle (LV) to the RV.12–16 Several parameters have been used to describe RV function (Table 1).
Prognostic use of echocardiography 1 year after a myocardial infarction
2005, American Heart Journal
Citation Excerpt :
However, in our analysis we found only a weak correlation between RV and LV systolic function. Thus, our data suggest that LV systolic function may have contributed to, but was not the only mechanism of RV dysfunction, an observation that is supported by other studies.27,28 Nevertheless, it is still possible that abnormalities of LV diastolic function, which would be expected to contribute to increased transpulmonary pressures, might be contributing independently to RV dysfunction.
Left ventricular (LV) and right ventricular (RV) function are known predictors of morbidity and mortality after an acute myocardial infarction (MI). However, the prognostic use of a late evaluation of cardiac function after an MI remains unclear.
We analyzed echocardiograms obtained 1 year after MI in patients with LV dysfunction at baseline (ejection fraction [EF] ≤ 40%) from 291 patients enrolled in the SAVE echocardiographic substudy who did not develop heart failure (HF) or a recurrent MI during this first year. Left ventricular EF and RV fractional area change were assessed.
After a median follow-up of 22 months after the 1-year echocardiogram, a low LVEF (<30%) at 1 year was associated with an increased risk of death and/or HF (hazards ratio [HR] 2.7, 95% CI 1.3-5.3). Presence of RV dysfunction was also associated with an increased risk of death (HR 8.9, 95% CI 3.5-22.1), development of HF (HR 7.1, 95% CI 3.4-15.0), and the composite end point of death or HF (HR 7.6, 95% CI 4.1-14.2). In multivariate analyses, both low LVEF and RV dysfunction remained independently predictive of the composite end point of death or HF. Patients with biventricular dysfunction were at the greatest risk of death and/or HF (HR 19.4, 95% CI 8.2-46.0) in follow-up.
In a stable population of survivors of MI, impaired LV and RV function at 1 year after MI are independently and additively predictive of increased risk of HF or death.
Right ventricular involvement in myocardial infarction and cardiogenic shock
2003, Lancet
Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction
2002, Journal of the American College of Cardiology
Citation Excerpt :
The greater prevalence of RV dysfunction in patients with a previous MI (50.6%) suggests that RV function may be a sensitive integrator of left atrial pressure over time. Nevertheless, our study, as well as others, suggests that RV function is largely independent of LV function (15,18), and that RV dysfunction may be more dependent on the location and extent of infarction than on the extent of LV dysfunction (26). Right ventricular infarction or ischemia in the setting of an inferior infarction could account for at least some of the RV dysfunction seen in the present study.
The aim of this study was to determine the prognostic value of right ventricular (RV) function in patients after a myocardial infarction (MI).
Right ventricular function has been shown to predict exercise capacity, autonomic imbalance and survival in patients with advanced heart failure (HF).
Two-dimensional echocardiograms were obtained in 416 patients with left ventricular (LV) dysfunction (ejection fraction [LVEF] ≤40%) from the Survival And Ventricular Enlargement (SAVE) echocardiographic substudy (mean 11.1 ± 3.2 days post infarction). Right ventricular function from the apical four-chamber view, assessed as the percent change in the cavity area from end diastole to end systole (fractional area change [FAC]), was related to clinical outcome.
Right ventricular function correlated only weakly with the LVEF (r = 0.12, p = 0.013). On univariate analyses, the RV FAC was a predictor of mortality, cardiovascular mortality and HF (p < 0.0001 for all) but not recurrent MI. After adjusting for age, gender, diabetes mellitus, hypertension, previous MI, LVEF, infarct size, cigarette smoking and treatment assignment, RV function remained an independent predictor of total mortality, cardiovascular mortality and HF. Each 5% decrease in the RV FAC was associated with a 16% increased odds of cardiovascular mortality (95% confidence interval 4.3% to 29.2%; p = 0.006).
Right ventricular function is an independent predictor of death and the development of HF in patients with LV dysfunction after MI.
Radionuclide assessment of right ventricular contractile reserve after acute myocardial infarction
1994, The American Journal of Cardiology
Conflicting data have been reported about the implications of a decreased right ventricular (RV) contractile reserve (i.e., a <5% stress-induced increase in ejection fraction [EF]). If a reduced reserve corresponds to ischemia, it will probably be associated with an electrocardiographic marker of RV ischemia, stress-induced ST-segment elevation (↑ST) in leads V₃R to V₆R. To test this hypothesis, 98 asymptomatic postinfarction patients (27 with RV infarction) were assigned to a dobutamine stress test (maximal dose 40 μg/kg/min) with equilibrium radionuclide angiography and electrocardiographic study, including leads V₃R to V₆R. All but 11 patients underwent coronary angiography. A dobutamine-induced ↑ST in VR leads was seen in 24 patients with and in 8 without RV infarction. This electrocardiographic sign was 75% sensitive and 84% specific for the diagnosis of proximal right coronary artery disease. It was 61% sensitive and 74% specific for the detection of reduced RV contractile reserve. Patients with RV infarction had reduced RVEF at rest (38 ± 9%), but the mean contractile reserve was normal (12 ± 12%). The contractile reserve was significantly smaller in patients with proximal versus distal or no right coronary artery disease. It was also smaller (p <0.01) in patients with ↑ST versus no ↑ST. In conclusion, high doses of dobutamine are useful in assessing RV contractile reserve after acute myocardial infarction. In these patients, a reduced RV contractile reserve is related to proximal right coronary artery disease and is associated with stress-induced ↑ST in VR leads.

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^☆: This study was supported by grant 3.966.080 from the Swiss National Foundation for Scientific Research, Bern, Switzerland.

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Original studyPrevalence and extent of right ventricular dysfunction after myocardial infarction — relation to location and extent of infarction and left ventricular function☆

Abstract

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Progr Cardiovasc Dis

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Right ventricular dysfunction detected by gated scintigraphy in patients with acute inferior myocardial infarction

Circulation

The noninvasive diagnosis of right ventricular infarction

Circulation

Functional response of the right ventricle to myocardial infarction: dependence on the site of left ventricular infarction

Circulation

Sequential assessment of left and right ventricular performance after acute transmural myocardial infarction

Ann Intern Med

Radionuclide assessment of sequential changes in left and right ventricular function following first acute transmural myocardial infarction

Am Heart J

Original study
Prevalence and extent of right ventricular dysfunction after myocardial infarction — relation to location and extent of infarction and left ventricular function☆