PREDICTIVE ROLE OF INFARCT  RELATED ARTERY IN ACUTE RIGHT VENTRICULAR  INFARCTION DIAGNOSED  USING  ELECTROCARDIOGRAPHY

Valentina Andova; Planinka Zafirovska; Vasil Papestiev; Ljubica Georgievska-Ismail

Valentina Andova University Clinic of Cardiology, Faculty of Medicine, Ss Cyril and Methodius University in Skopje, North Macedonia
Planinka Zafirovska Zan Mitrev Clinic, Faculty of Medicine, Goce Delcev University in Shtip, North Macedonia
Vasil Papestiev University Clinic of Cardiac Surgery, Faculty of Medicine, Ss Cyril and Methodius University in Skopje, North Macedonia
Ljubica Georgievska-Ismail University Clinic of Cardiology, Faculty of Medicine, Ss Cyril and Methodius University in Skopje, North Macedonia

Abstract

Right coronary artery (RCA) emerged as infarct related artery (IRA) in patients with right ventricular myocardial infarction (RVMI), which is followed by some degree of RV dysfunction. The aim of our study was to identify significant predictors of IRA among angiographic and/or echocardiographic data of RV dimension and/or function in patients with acute RVMI. Out of 122 hospitalized patients with acute inferior myocardial infarction, on the basis of ECG criteria RVMI was diagnosed in 58/47.5% patients. Coronary angiography was applied in 52/89,6% immediately after admission and conventional 2D echocardiography was performed in all referred patients in order to assess right heart dimensions and function according to the professional association recommendations. RCA emerged as IRA in 49/84,5 % of patients with echocardiographicaly diagnosed RVMI. Patients with RCA stenosis/occlusion had 4.9 times higher risk for RVMI presence (OR=4.941; 95%CI: 1.727-14.136; p=0.003) than those without and had significantly worse echocardiographic assessed RV global and/or regional systolic function. Logistic stepwise regression analysis confirmed the significant role of enlarged RV dimension (OR=1.1; 95%CI: 1.023-1.182; p=0.010), RCA stenosis/occlusion presence (OR=4.8; 95%CI: 1.649-14.199; p=0.004) and/or LAD stenosis/occlusion absence (OR=0.18; 95%CI: 0.067-0.476; p=0.001) in prediction of RVMI. The optimal sensitivity of the model was 90% and specificity 75%. RCA and conversely lack of LAD stenosis/occlusion presence along with some of the echocardiographic parameters showing RV dysfunction increased the odds for RVMI. Applying immediate and complete reperfusion of RCA is of a great importance for recovery of RV function.

Key words: right myocardial infarction, right coronary artery, right ventricular dysfunction, reperfusion.

References

1. Andersen HR, Falk E, Nielsen D. Right ventricular infarction: frequency, size, and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am Coll Cardiol 1987;10:1223-32.
2. Kinch J W and Ryan TJ. Right ventricular infarction. N Engl J Med.1994;330:1211-7.
3. Goldstein JA. Patophysiology and management of right heart ishcemia. J Am Coll Cardiol 2002; 40:841-53.
4. Isner JM, Roberts WC. Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease. Frequency, location, associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction. Am J Cardiol 1978;42:885-94.
5. Lopez-Sendon J, Coma-Canella I, Alcasena S, et al. Electrocardiographic findings in acute right ventricular infarction: Sensitivity and specificity of electrocardiographic alterations in right precordial leads V4R, V3R, V1, V2 and V3. J Am Coll Cardiol 1985;6:1273–1279.
6. Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute myocardial infarction. N Engl J Med 1993;328:981-8.
7. Somers MP, Brady WJ, Bateman DC, et al. Additional electrocardiographic leads in the ED chest pain patient: right ventricular and posterior leads. Am J Emerg Med. 2003;21:563–573.
8. Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003;348:933–40.
9. Verouden NJ, Barwari K, Koch KT, et al. Distinguishing the right coronary artery from the circumflex coronary artery as the infarct-related artery in patients undergoing primary percutaneous coronary intervention for acute inferior myocardial infarction. Europace 2009;11:1517-21.
10. Thygesen K, Alpert JS, Jaffe AS, et al on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/ American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2018; 00:1-33.
11. Yasuda T, Okada RD, Leinbach RC, et al. Serial evaluation of right ventricular dysfunction associated with acute inferior myocardial infarction. Am Heart J 1990;119:816-22.
12. Goldberger JJ, Himelman RB, Wolfe CL, et al. Right ventricular infarction: recognition and assessment of its hemodynamic significance by two-dimensional echocardiography. J Am Soc Echocardiogr. 1991;4:140-6.
13. Jiang, L, Levine RA, Weyman AE. Echocardiographic assessment of right ventricular volume and function. Echocardiography 1997; 14: 189–206.
14. Horton KD, Meece RW and Hill JC. Assessment of the right ventricle by echocardiography: A primer for cardiac sonographers. J Am Soc Echocardiogr 2009;22:776-92.
15. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardio- graphic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the Euro- pean Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23:685–713.
16. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1–39.e14.
17. Berger PB, Ryan TJ. Inferior myocardial infarction: high-risk subgroups. Circulation 1990;81:401-11.
18. Mehta S, Eikelboom J, Natarajan M, et al. Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction. J Am Coll Cardiol 2001;37:37-4.
19. Jacobs AK, Leopold JA, Bates E, et al. Cardiogenic shock caused by right ventricular infarction. A Report from the SHOCK Registry. J Am Coll Cardiol 2003;41:1273-9.
20. Laster SB, Ohnishi O, Safitz JE, Golstein JA. Effects of reperfusion on ischemic right ventricular dysfunction. Disparate mechanism of benefit related to duration of ischemia. Circulation 1994; 90:1398-409.
21. Bowers TR, O’Neill WW, Pica M and Goldstein JA. Patterns of coronary compromise resulting in acute right ventricular ischemic dysfunction. Circulation 2002; 106:1104-9.
22. Tomala M, Miszalski-Jamka T, Zajdel W, et al. Angiographic result of index PCI determines the presence of right ventricular infarction in patients with acute inferior myocardial infarction. Int J Cardiovasc Imaging. 2015; 31(8):1591-601.
23. Bowers TR, O’Neill WW, Grines C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med. 1998; 338:933–940.
24. Sianos G, Morel M-A, Kappetein AP, et al. The SYNTAX Score: and angiographic tool grading the complexity of coronary artery disease. EuriInterv 2005;1:219-27.
25. Zehender M, Kasper W, Kauder E, Geibel AN, Schonthaler M, Olschewski HJ, Just H: Eligibility for and benefit of thrombolytic therapy in inferior myocardial infarction: Focus on the prognostic importance of right ventricular infarction. J Am Coll Cardiol 1994; 24:362-9.
26. Berger PB, Ruocco NA Jr, Ryan TJ, et al, and the TIMI research group. Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thrombolytic therapy: Results from the Thrombolysis in Myocar- dial Infarction (TIMI II) trial. Am J Cardiol 1993;71:1148-52.
27. Kidawa M, Kasprzak JD, Wierzchowski T, Krzeminska-Pakula M. Right ventricular function suffers from reperfusion delay: Tissue Doppler Study. Clin Cardiol 2010;22:E43-E48.
28. Goldstein JA, Lee DT, Pica MC, et al. Patterns of coronary compromise leading to bradyarrhythmias and hypotension in inferior myocardial infarction. Coron Artery Dis 2005; 16: 265-274.