What clinical signs on physical examination would you expect in a non-ventilated patient with a right ventricular infarct?    (25% marks)

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College answer

  • 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.

Examiner's comments:

Part b was answered poorly - candidates listed the signs of right ventricular failure, not of a right ventricular infarct.

Discussion

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 wave in the significantly raised JVP
    • Right-sided third  heart sound (augmented by inspiration)
    • Peripheral oedema
    • Ascites
    • 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)

References

References

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.