What clinical signs on physical examination would you expect in a non-ventilated patient with a right ventricular infarct? (25% marks)
- Clinical signs would include the triad of hypotension, elevated JVP and clear lung fields
- Pulsus paradox
- Kussmaul’s sign (elevation of JVP on inspiration)
- Right sided gallop S3/4.
Part b was answered poorly - candidates listed the signs of right ventricular failure, not of a right ventricular infarct.
The signs of right heart failure, which we were not supposed to specifically mention, would surely develop with a right sided infarct, and therefore reveal it to be right sided.
"The clinical triad of hypotension, clear lung fields, and elevated jugular venous pressure in a patient with an inferior infarction is virtually pathognomonic for right ventricular infarction." However, the triad has a sensitivity of 25% (Kinch et al; 1994). Other signs may include:
- Kussmaul's sign
- Distended neck veins
- Tricuspid regurgitation
- Gallop rhythm
- AV dissociation (i.e. conduction abnormalities)
Anyway: features of right heart failure will not have time to develop with acute infarction, but here they are anyway:
- Features attributable to pulmonary hypertension
- Loud P2(may be palpable)
- Narrowly split S2
- Tricuspid murmur
- Diastolic murmur of pulmonary regurgitation
- Features attributable to RV hypertrophy
- Prominent a wave in the JVP
- Right-sided fourth heart sound (augmented by inspiration)
- Left parasternal heave
- Downward subxiphoid thrust.
- Features attributable to RV dilatation and decompensated failure
- Prominent v wave in the significantly raised JVP
- Right-sided third heart sound (augmented by inspiration)
- Peripheral oedema
- Hepatomegaly (which may be pulsatile)
- Signs of LV failure, eg. pulmonary oedema (due to out-bowing of the intraventricular septum, and LV diastolic failure resulting from this)
Lorell, Beverly, et al. "Right ventricular infarction: clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction." The American journal of cardiology43.3 (1979): 465-471.
Kinch, Jack W., and Thomas J. Ryan. "Right ventricular infarction." New England Journal of Medicine 330.17 (1994): 1211-1217.