hemodynamic criteria for diagnosis of right ventricular ischemia associated with inferior wall left...

Hemodynamic Criteria foi Diagnosis of Right VeiMcular lschemia Associated

With Inferior Wall Left Ventricular Acute Myocardial Infarction

Ariel Cohen, MD, Philippe Guyon, MD, Nicolas Johnson, MD, Christbphe Chauvel, MD, Damien Logeart, MD, Dominique Costagliola, PhD, and Jean Valty, MD

To test the diagnostic value of different hemo d7”

amic indexes for the diagnosis of acute right ventricu ar (RV) ischemic dysfunction, we studied 2 groups of consecutive patients admitted for an acute left ventricular inferior wall myocardial infarction: 5 1 patients with (group 1) and 32 patients without (group 2) RV ischemia as determined b coronary angiography. In both groups, we analyz ecr by right-sided cardiac catheterization right-sided heart pressures, pulmonary ca pressure, and cardiac index. We also

illary wedge ca culated pres- P

sure ratios (mean right atrial pressure or RV end-diastolic over pulmonary capillary wedge pressures),

% ul-

monary vascular resistance, and RV stroke work in ex. We found significant differences (p ~0.01) between the 2 groups when comparing mean right atrial pressure, RV end-diastolic ressure, ratio of these 2 pressures over pulmonary ca

Ii i R ary wedge press&, RV stroke work

index, and rig t atrial and RV pressure waveforms. The best combined sensitivity, specificity, value, negative

cr redictive value, an dp

ositive predictive

mcy were foun diagnostic accu-

for the right atrial M or W waveform

pattern, isolated or combined with a disproportionate elevation of RV end-diastolic over pulmonary capillary wedge pressures (respectively, 92%, 94%, 90%, 87%, and 89%). Volume loading was performed in 27 patients (18 with and 9 without RV ischemia). Right heart pressures and RV stroke work index inqeased signifi- cqntiy and similarly in both groups. Cardiac index increased significantly only in patients without RV ischemia (p = 0.02). However, volume loading did not significantly modify the dia nostic value of the different hemodynamic criteria stu 8 ied. Moreover, no significant difference was observed with regard to clinical characteristics or in-hospital complications in patients with a right atrial M or W waveform pattern. Thus, the diagnosis of RV ischemia can be achieved with a high diagnostic accuracy when considering the presence of an M or W right atrial waveform pattern, alone or combined with a disproportionate elevation of ri

J ht heart

filling compared with pulmonary capillary w ge ressure, with no significant modification with volume oad- P ing. (Am J Cardiol 1995;76:22&225)

R ecognition of ischemic right ventricular (RV) dysfunction in the course of an inferior wall left ven-

tricular (LV) acute myocardial infarction is important in clinical practice, because it is associated with a higher in-hospital morbidity and mortality,1,2 although the long- term course may be favorable.3 The diagnosis of RV infarction can be made from the physical examination,4 electrocardiography,5Jj Doppler and 2-dimensional echocardiography,7 scintigraphy,3,8,g or RV angiography. lo All these diagnostic methods were initially compared with the gold standard of hemodynamic assessmentn,12 or au- tdpsy.13 However, most published series were performed in compromised patient&l2 and numerous hemodynamic criteria were used.14 The diagnostic value of different hemodynamic criteria has not been systematically studied in consecutively admitted patients with inferior wall LV acute myocardial infarction. Therefore, using coronary angiography as a reference investigation for RV ischemia,15916 we aimed to evaluate various hemodynamic parameters in consecutive patients with (group 1) or without (group 2) a culprit lesion on the right coro-

From the Department of Cardiology, Saint-Antoine University Hospi- tal, and the Saint-Antoine Medical School, Paris, France. Manuscript received March 22, 1995; revised manuscript received and accept- ed May 22, 1995.

Address for reprints: Ariel Cohen, MD, Department of Cardiolo gy, Saint-Antoine University Hospital, 184 Rue du Faubourg Saint- Antoine, 75571 Paris Cedex 12, France.

220 THE AMERICAN JOURNAL OF CARDIOLOGY@ VOL. 76

nary artery proximal to the origin of an RV branch. We also aimed to evaluate the potential additive diagnostic value of volume loading in such patients.

METHODS Study group: Eighty-three consecutive patients (75

men and 8 women, mean age 54.7 + 10.6 years [range 40 to 751) admitted to the coronary care unit at Saint- Antoine University Hospital, Paris, France, for LV inferior wall acute myocardial infarction were prospective- ly investigated. Inclusion criteria were as follows: (1) prolonged chest pain (230 minutes) despite nitroglycerin infusion; (2) electrocardiographic evidence of >l mm ST-segment elevation in 22 inferior leads (II, III, aVF); (3) more than a twofold increase in plasma creatine kinase; and (4) sinus rhythm at the time of hemodynamic evaluation. Exclusion criteria were as follows: previous myocardial infarction, chronic bronchitis, high-degree atrioventricular block or paroxysmal supraventricular tachycardia, and significant pericardial effusion on 2- dimensional echocardiography.

All patients were examined for clinical evidence of RV involvement (spontaneous elevated jugular pulse pressure, right-sided heart failure, spontaneous or nitroglycerin-induced systemic hypotension, or other signs of low output or shock).

An electrocardiogram, including RV precordial leads V,R, V,R, and V,R, was systematically recorded. RV

AUGUST 1, 1995

involvement was suspected when an ST- segment elevation 21 mm in lead V,R was present.”

Right-sided cardiac catheterization: of- ter informed consent was obtained, all patients underwent right-sided cardiac catheterization within the first 48 hours of admission. A flow-directed balloon catheter (7Fr Swan-Ganz type catheter, Baxter Healthcare Corporation [Edwards Divi- sion], Irvine, California) was introduced

D2

20

RA

mmHgo

percutaneously through a large vein after FIGURE 1. Tracings of simultaneous M pattern of right atrial (RA) pressure and

local anesthesia. Pressures were recorded electrocardiogram (D2). M ttern corn

simultaneously with the electrocardiogram a small V wave, and a Y 8” P rises a &pressed A wave, an X descent,

escent equa to or deeper than the X descent.

at paper speeds of 25,50, and 100 mm/s, and cardiac output was determined using a thermodilution system.

Measurement of hemodynamic parameters at baseline: Mean right atrial, systolic, early diastolic, and end- diastolic RV pressures as well as pulmonary artery and mean pulmonary capillary wedge pressures were mea- sured. Three different scales were used for the record- ing of right atrial and RV pressures.

We also paid great attention to the right atria1 pres- 10 A A

sure waveform. The different right atrial pressure wave- xc v c v *cv

form components were defined as follows: the A wave was the first positive deflection after the P wave on the

RA electrocardiogram, the X descent was the first negative I\ X’ Y x Y ’ Y

wave after the A wave, the V wave was the last positive mmHg 01

deflection before the next A wave, and the Y descent was the negative wave after the V wave and just before FIGURE 2. Tracin

(RA) pressure an 1 s of simultaneous W pattern of right atrial

the subsequent A wave. The term M or W right atrial electrocardiogram (D2). W pattern comprises

pressure waveform, or noncompliant pattern, was used a prominent A wave, an X descent before a C wave, an X’ s stalic

when the Y descent was at least as steep as the X de- J descent, a V wave, and a Y descent equal ta or deeper

an the X descent. scent, the M pattern being observed when there was a diminutive A wave (Figure l), and the W pattern (Fig- ure 2) when the A wave was prominent, according to the work of Lopez-Sendon et a1.13 We also carefully ex-

consecutive concordant values for cardiac output was determined. All pressure tracings were analyzed by 2 in-

amined the RV pressure waveform, looking for the pres- dependent observers who were blinded to the clinical ence of RV “dip-and-plateau” pattern, defined as an ear- history of the patients. ly diastolic dip, and a mid- and late diastolic plateau, the left-sided cardiac catheterization: Two to 7 days after value of which was at least one third of the systolic pres- admission (mean 7 + 3), LV and coronary angiography sure value. Cardiac index was calculated according to were performed. Global LV ejection fraction was calcu- the following formula: cardiac index = cardiac output/ lated using the Dodge method. RV involvement was sus- body surface area. RV stroke work index was calculat- pected in the presence of right coronary artery occlusion ed with the formula: 0.0136 . cardiac index l (mean pul- or right coronary artery stenosis 170%, proximal to the monary artery pressure - right atrial pressure)/heart rate. first RV free-wall branch (RV+, group 1). Patients hav- We also calculated pressure ratios: right atrial pres- ing a culprit lesion on the right coronary artery distal to sure/pulmonary capillary wedge pressure, RV end-dias- the origin of the RV branch or on the left circumllex tolic pressure/pulmonary capillary wedge pressure, and artery were considered as free from RV ischemia (RV-, pulmonary vascular resistance according to: pulmonary group 2). vascular resistance = 80 l (mean pulmonary artery pres- Statistical analysis: All values are expressed as mean sure - pulmonary capillary wedge pressure)/cardiac output (dynes*s*cm-5).

+ SD. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were determined

MEASUREMENTSOFHEMODYNAMICPARAh4ETERSAFIER using standard formulas. Differences in data between VOLUME LOADING: All hemodynamic parameters were patients with and without RV involvement were analyzed determined in the first 27 consecutive patients after vol- using parametric and nonparametric statistical tests. ume loading by rapid intravascular administration of flu- The Student’s t test and Mann-Whitney U test were id gelatin in 150 ml increments over 5 minutes. The cri- used to evaluate group differences. The 2-tailed Fisher’s terion for interruption of volume expansion was mean exact tests and chi-square procedures were performed to pulmonary capillary wedge pressure value >15 mm Hg. test for categorical variable differences between the

Three determinations for each hemodynamic para- groups. A p value co.05 was necessary to achieve sta- meter were made and the results averaged. A mean of 5 tistical significance.

CORONARY ARTERY DISEASE/HEMODYNAMICS IN RIGHT VENTRlCUlAR INFARCTION 221

TABLE I Baseline Demographic and Clinical Characteristics in Patients With and Without Right Ventricular Involvement

Group 1 Group 2

W+l W-1 (n = 51) (n = 32) p Value

Age (yd 56* 10 53 f 12 0.140 Men/women 46/5 29/3 0.751 Thrombolysis (%) 38 (75) 23 (72) 0.993 CreaHne kinase (IU/L) 1,059 zt 781 1,002 zt 839 0.754 Clinical signs suggesting 26 (51) 6 (19) 0.007

RV involvement (%) :I’,’ ;;” in V,R (%) 29 (57) 2 (6) co.00 1

4 0 20 (39) 2 (61 co.00 1

Quantitative variables clre expressed os mean * SD. RV+, RV- = with and tiithout right ventricular involvement, respectively.

RESULTS There were 51 patients (61%) with (RV+, group l),

and 32 patients (39%) without RV ischemia (RV-, group 2). There were no sign&ant differences between the 2 groups with regard to age, sex, atherosclerotic risk factors, and percentage of patients having received thrombolytic therapy. Patients with and without RV involvement differed with regard to the presence of clinical signs of right-sided heart dysfunction (51% vs 19%, p = 0.007). Low-output syndrome was present in 10 patients with RV involvement. ST-segment elevation 21 mm in V,R as well as Q wave in V,R were seen more frequently in the group with ischemic RV dysfunction (57% vs 6% and 39% vs 6%, p ~0.001, respectively). The time between onset of chest pain and electrocardiographic registration was not statistically different in the 2 groups (9.4 + 13.1 and 9.3 f 9.8 hours, respectively, p = 0.94). Creatine kinase maximal levels were not significantly different in the 2 groups (Table I).

Coronary arteriography and left ventriculography. The culprit lesion was exclusively on the right cbronary ar-

TABLE II Baseline Angiographic Data in Patients With and Without Right Ventricular Involvement

,Group 1 Group 2

W+l WI (n = 51) (n = 32) p Value

Culprit coronary artery Right proximal to RV branch 51 0 Right distal to RV branch 0 19 Left circumflex 0 11

<o.oo 1

Normal 0 2 1 Number of coronary arteries 1.67 * 0.73 1.28 * 0.73 0.020

involved Right stenosis ~50% (%) 51 (100) 22 (69) ~0.001 Right stenosis 270% (%) 50 (98) 19 (59) eo.001 LV ejection fraction (%) 53 f 11 53*11 1 Mitral regurgitation (%) 9 (181 5 (16) 0.95 1

Quantitative variables are expressed os mean * SD. LV = left ventricular; RV = right ventricular; RV+, RV- : with and without

right ventricular involvement, respectively.

tery in group 1 because of the population selection; right coronary artery stenosis 270% distal to the origin of the RV branch was seen in 59% of group 2 patients. The level of the culprit lesion, the number of diseased coronary vessels, and the percentage of patients in each group having a stenosis of.the right coronary artery of 250% or 70% were significantly different. Right coronary artery occlusion proximal to the RV branch at the time of coronary tigiography was present in 15 group 1 patients (29%). LV ejection fraction was identical in the 2 groups (Table II).

Right-sided cardiac catheterization: BASELINE HEMO- DYNAMIcDATAINTHEWHOLESERIES(N= 83): Meanright atrial and RV end-diastolic pressures, mean right atrial over pulmonary capillary wedge pressure ratio, and RV end-diastolic over pulmonary capillary wedge pressure ratio were significantly higher in group 1 (Table IlI). Eighty-six percent of group 1 patients had an M or W

TABLE Ill Baseline Hemodynamic Data in the Whole Series Including Consecutive Patients With and Without Right Ventricular Involvement According to Coronary Angiography Classification

Group 1 Group 2

N’+l W-1 Parameters (n = 51) (n = 32) p Value

Heart rate (beats/min) 70 f 11 64 i 9 0.011 Mean right atrial pressure (mm Hg) 10.0 i 4.0 7.3 * 4.6 0.006 RV systolic pressure (mm Hg) 27.6 i 6.1 28.4 * 8.2 0.613 RV early diastolic pressure (mm Hg) 5.6 i 3.6 RV enddiastolic pressure (mm Hg)

4.5 f 4.3 0.213 14.3 Et 4.4 9.4 A 4.8 <O.OOl

Systolic pulmonary artery pressure (mm Hg) 26.6 +z 6.1 27.8 i 8.0 0.442 Diastolic pulmonary artery pressure (mm Hg) 12.9 * 3.9 12.3 i 5.1 0.547 Mean pulmonary artery pressure (mm Hg) 19.0 * 4.7 18.5 i 5.5 0.660 Pulmonary capillary wedge pressure [mm Hg) 13.3 * 3.8 13.9 * 5.4 0.554 Mean right atrial pressure/pulmonary 0.75 ct 0.26 0.50 zt 0.17 <O.OOl

capillary wedge pressure RV end-diastolic pressure/pulmonary 1.16 f: 0.54 0.66 zt 0.15 ~0.001

capillary wedge pressure Cardiac index (L/min/m*) 2.8 e 1.1 2.7 i 0.6 0.639 Pulmonary vascular resistance (IU) , 1.2 * 0.9 0.9 sz 0.6 0.100 RV stroke work index (g-m-m-2) 2.6 * 2.5 4.9 * 2.5 <0.001 Right atria1 pressure waveform (M/W/normal) 1 l/34/6 1 /o/3 1 co.00 1 RV dip-and-plateau pattern (%) 29 (57) 1 (3) co.oo1

Quantitative variables clre expressed as mean * SD. Abbreviations OS in Tables I and II.

right-at&l pr&sure waveform versus 3% in group 2 (p ~0.001). RV dip-and- plateau pattern was seen more often in the group with RV ischemia (57% vs 3%, p ~0.001). No sig@cant difference was observed with regard to RV systolic and early diastolic, pulmonary, and wedge pressures as well as cardiac index and pulmdnary vascular resistance.

VOLUMELOADING(N= 27): Hemo- dynamic data at baseline and after volume loading were compared in the first 27 consecutive patients (18 with and 9 without RV ischemia). This prelimi- nary study was designed to better char- acterize the diagnostic impact of volume laading in the evaluation of RV ischemic dysfunction. We found a sig- ticant increase in all pressure measurements (13% to 39%, p <O.OOl) as well as RV stroke work index (53%, p = 0.017) after volume loading. However, the only difference between the 2 sub- groups with or without RV ischemia was a significantly higher increase in

222 THE AMERICAN JOURNAL OF CARDIOLOGY@ VOL. 76 AUGUST 1, 1995

cardiac index in patients without RV ischemia (p = 0.02). There was no significant increase after volume loading with regard to pressure ratios and pulmonary vascular resistance (Table IV).

RIGHT-SIDEDHEARTPRESSURETRAC- LNGS: Table V summarizes the main clinical, electrocardiographic, and hemodynamic characteristics of patients with ischemic RV dysfunction according to the presence of baseline right atria1 pressure M (n = 11) or W (n = 34) patterns (6 normal pressure waveforms). There was no significant difference between these 2 groups except for a higher mean right atrial pressure in patients with right atrial M pattern (13.3 & 5.4 vs 9.7 AI 4.3 mm Hg, p = 0.030). Interestingly, the occurrence of in-hospital complications including ischemic recurrence, severe arrhythmias, complete heart block, and low-output syndrome, was similar in both groups (55% vs 44%, p = 0.932). Lastly, right atrial pressure waveforms did not change significantly in 18 patients with RV ischemic dysfunction who had volume

TABLE IV Hemodynamic Data in the Subgroup of 27 Patients-l 8 With and 9 Without Right Ventricular Involvement at Baseline and Aher Volume Loading

RV+ RV- (n = 18) (n = 9)

Volume Volume Baseline Loading Baseline Loading p Value

Pressures (mm Hg) Mean right atrial 9.4 AS 3.5 12.7 A 4.2 7.2 e 4.4 8.4 zt 3.9 0.300 RV early diastolic 5.6 zk 3.7 8.8 * 4.4‘ 4.9 f 3.8 4.7 f 4.5 0.100 RV end-diastolic 14.9 f 3.8 18.9 zt 4.3 9.9 zt 4.5 13.2 zt 4.4 0.360 Mean pulmonary 19.1 * 4.1 22.9 i 4.8 16.4 i 5.5 19.8 i 5.2 0.830

artery

Pulmonary capillary 12.7 * 3.3 17.4 * 3.8 13.2 * 5.5 15.4 * 4.1 0.750 wedge

Mean right atrial/ 0.74 i 0.21 0.74 A 0.23 0.52 zt 0.21 0.53 + 0.17 0.770 pulmonary capillary wedge

RV end-diastolic/ 1.22 * 0.37 1.10 zt 0.19 0.74 * 0.15 0.85 i 0.15 0.100 pulmonary capillary wedge

Cardiac index 2.8 zt 1.0 3.5 * 0.9 2.8 * 0.8 4.7 ct 1.4 0.020 (L/min/m2)

Pulmonary vascular 1.3 f 0.7 0.9 f 0.5 0.5 * 0.7 0.5 f 0.4 0.510 resistance (IU)

RV stroke work index 5.6 f 3.5 7.4 + 4.6 4.4* 1.9 9.7i4.5 0.180 (g.m*m-*)

Quantitative variables are expressed as mean * SD. Abbreviations as in Tables I to III.

loading (6 M, 11 W, and 1 normal right atrial pressure pattern before volume loading, and 5 M and 13 W right atrial pressure pattern after volume loading).

DIAGNOSTICVALUEOFVARIOUSHEMODYNAMICPARA- METERS (TABLE VI): The presence of an M or W right atrial pressure waveform pattern and a disproportionate increase of right heart filling pressures compared with pulmonary capillary wedge pressure had an excellent diagnostic value in the whole series as well as in the subgroup of 27 patients who had volume loading. On the other hand, a mean right atrial pressure of 210 mm Hg, RV end-diastolic pressure 210 mm Hg, cardiac index 12.5 L/min/m2, and the presence of an RV dip-and- plateau pattern had poor sensitivity and accuracy in the diagnosis of RV ischemic dysfunction, although specificity was good. The presence of an M or W right atrial pressure combined with a disproportionate increase in RV end-diastolic versus pulmonary capillary wedge pressure (pressure ratio 20.8) increased the sensitivity in detecting RV ischemia, but the specificity was lower. Of note is the absence of a further increase in the diagnostic accuracy of these various hemodynamic parameters after volume loading (data not shown).

DISCUSSION The present study indicates that in a selected but large

series of patients with inferior wall LV acute myocardial infarction, the best diagnostic accuracy for the recognition of RV ischemic dysfunction, as determined by coronary angiography, was obtained in the presence of a right atrial pressure noncompliant pattern isolated or combined with a disproportionate increase in right heart filling pressure relative to pulmonary capillary wedge pressure. Furthermore, we did not find any additional diagnostic value after volume loading for these parameters.

TABLE V Characteristics of Group 1 Patients (RV+) Who Had Rig1 Atrial Pressure M (n = 11) or W (n = 34) Patterns

Parameters

Right Atrial Right Atrial Pressure M Pressure W

Pattern Pattern (n= 11) (n = 34) p Valut

Age (yrl 55 + 11 Thrombolysis (%) 5 (45) Clinical signs suggesting 5 (45)

RV involvement (%) Creatine kinase (IU/L) 1,012 + 671 ST’? ~1 mm in V,R (%) 6 (55) Q V,R (“A) 6 (55) Mean right atrial pressure 13.3 * 5.4

(mm Hgl Cardiac index (L/min/m2) 2.3 * 0.8 Pulmonary capillary wedge 13.3 * 3.8

pressure (mm Hg) In-hospital complications (%* 6 (55)

58 f 8 0.331 27 (79) 0.076 13 (38) 0.944

1,146 r.t 867 0.642 23 (68) 0.670 13 (38) 0.548

9.7 * 4.3 0.030

3.0 * 1.2 0.660 13.9 f 5.4 0.105

15 (44) 0.932

*Ischemic recurrence, severe arrhythmias, complete heart block, and low- output syndrome.

Quantitative variables are expressed CIS mecm * SD. Abbreviations c15 in Tables I to III.

Clinical and dectracardiagraphic featvres: III our series, as in other published series, clinical parameters revealed insufficient sensitivity for the diagnosis of RV ischemia, although there was good specificity. ST-segment elevation >l mm or the presence of a Q wave in lead V,R, still considered to be the best electrocardiographic criteria, lack sensitivity, although their specificity is good.5-7 The diagnostic accuracy of electrocardiographic signs was not modified when considering different time inter- vals between onset of chest pain and electrocardiographic registration.

CORONARY ARTERY DISEASE/HEMODYNAMICS IN RIGHT VENTRICULAR INFARCTION 223

TABLE VI Diagnostic Accuracy of Various Hemodynamic Parameters Determined at Baseline in 83 Consecutive Patients With Acute Inferior Wall Myocardial Infarction With (n = 51) and Without (n = 32) Right Ventricular Involvement

Positive Negative Sensitivity Specificity Predictive Predictive Accuracy

WI WI Value (%) Value (%) PI

Mean right atrial pressure ~10 mm Hg 57 78 81 53 RV end-diastolic pressure 210 mm Hg 55 69 82 81 ii; Mean right atrial pressure/pulmonary capillary wedge pressure 20.8 43 97 96 52 64 RV enddiastolic pressure/pulmonary capillary wedge pressure ~0.8 86 84 90 79 86 Cardiac index 22.5 L/min/m* 55 53 65 43 54 RV dip-and-plateau pattern 57 97 97 58. 72 M or W right atrial pressure waveform 86 97 98 82 90 M or W right atrial pressure woveform or RV enddiastolic pressure/ 92 94 90 87 89

pulmonary capillary wedge pressure 20.8 M or W right atrial pressure waveform and RV end-diastolic pressure/ 80 97 98 76 87

pulmonary capillary wedge pressure ~0.8 M or W right atrial pressure waveform or mean right atrial pressure/ 86 97 98 82 90

pulmonary capillary wedge pressure to.8 M or W right atrial pressure waveform and mean right atrial pressure/ 43 97 96 52 64

pulmonary capillary wedge pressure 20.8

Hemodynamic features of right ventricular involvement: Right-sided cardiac catheterization with hemodynamic measurements is still considered as the reference investigation for the diagnosis of RV infarction or dysfunction, or both; related to RV ischemia.U-13 However, most published studies rely on short series, with a hetero- geneous population and reference investigation.’ Fur- thermore, the diagnostic value of different hemodynamic criteria has not been systematically studied in consecutively admitted patients with acute LV inferior wall myocardial infarction. Finally, the diagnostic12J3J8 and therapeutic16J9 impact of volume loading in such circumstances has recently been challenged.

EFFECTS OF VOLUME LOADING: In our series (n = 27 consecutive patients), a significant increase in all pressure measurements was observed compared with measurements in other studies.13,16J8-20 However, results of the cardiac index were quite different. These investiga- tors showed that cardiac index was unchanged after volume loading, whereas Dhainaut et al,21 in agreement with our own observations, reported a modest but statistically significant increase in cardiac index in patients with RV involvement. This discrepancy may be related to sev- eral factors: (1) the baseline level of the cardiac index, which was within normal values in our series; (2) the lack of atrioventricular synchronization in some stud- ies19; and (3) the heterogeneity of diagnostic reference used for recognition of RV involvement. Of note is the absence of additive diagnostic value of volume loading with regard to the presence of an RV dip-and-plateau pattern or a right atrial pressure noncompliant pattern.

Diagnostic accuracy of various hemodynamic pcwame- ters: RIGHT ATRlAL PRESSURE NONCOMPLIANT PATTERN: This hemodynamic parameter was, in our opinion, the best hemodynamic index for the diagnosis of RV ischemia, alone or associated with a disproportionate increase in right heart filling pressures versus pulmonary capillary wedge pressures. In the 2 most important series, this index was also considered the best for diagnosis of RV infarction. Lopez-Sendon et aln reported a sensitivity of 82% and a specificity of 97% for the following para-

224 THE AMERICAN JOURNAL OF CARDIOLOGY@ VOL. 76

meter: mean right atrial pressure = pulmonary capillary wedge pressure according to defined limits, or presence of a severe noncompliant pattern, in a series of 60 patients admitted for an acute myocardial infarction (47% of inferior topography), with anatomically proven RV infarction. Dauber-t et al,‘O in a series of 40 patients with RV involvement proved with conventional right ventriculography, reported a 90% sensitivity and 95% specificity for the adiastolic pattern, in which they include a Wright atrial pressure waveform, an RV dip-and-plateau pattern, and near equalization of diastolic right heart pressures. It is noteworthy that these 2 studies included severely ill patients. In other series, sensitivity was also high, from 75% for Coma-Canella and Lopez-Sendon22 to 100% for Daubert et al.‘O Lore11 et a123 only reported 42% of an M or W pattern, defined as a Y descent steep- er than the X descent, in a series of 12 patients. Gold- stein et all2 observed an excellent sensitivity (100%) in a series of 16 patients with hemodynamically severe RV infarction, but the noncompliant right atrial pattern was defined as a blunted Y descent compared with the X descent, and all patients had elevated mean right atrial pressure. This investigator underlined the prognostic impli- cation of right atrial function, assessed by the A-wave pattern. Our series, which included consecutively admitted patients with inferior LV wall acute myocardial infarction, failed to co&m a higher incidence of in-hospital complications, although an M pattern was seen more often in patients with low-output syndrome (5 of 10 vs 4 of 41, p = 0.01). In addition, a right atrial pressure waveform was not significantly modified by volume loading, whereas Lopez-Sendon et all3 reported the presence of a noncompliant pattern after volume loading in 3 of 22 patients with RV infarction.

DISPROPORTIONATE ELEVATION OF RIGHT HEART FlLL- ING PRESSURE COMPARED WITH PULMONARY CAPILLARY WEDGE PRESSURE: This was also a good hemodynamic criterion in our series in terms of diagnostic value, but only if we considered RV end-diastolic pressure and not right atrial pressure, which had a poor diagnostic value, although it was one of the earliest proposed diagnostic

AUGUST 1, 1995

hemodynamic criterion. n Finally, RV stroke work index, cardiac index, and the presence of an RV dip-and-plateau pattern had a poor diagnostic value.

Study limitations: One limitation of our study is related to the reference investigation for the diagnosis of RV ischemia (i.e., coronary arteriography). We defined RV ischemia as the presence of the culprit lesion on the right coronary artery proximal to the first RV branch. With this definition, we did not include RV ischemia associated with left coronary artery disease.24,25 In addition, the delay between right-sided cardiac catheterization and coronary angiography was approximately 1 week and thus could lead to an underestimation of right coronary artery thrombosis, However, 29% of group 1 patients still had an occlusion and we do not think that the degree of stenosis could be modified within a few days. This delay was similar to that reported by Lew et a1,15 but Braat et al6 did not mention it. Furthermore, as reported by Laster et a12(j in an experimental study, early reperfusion after right coronary occlusion (73% of patients had thrombolysis in our series) did not normalize RV end-diastolic pressure despite prompt recovery of re- gional and global RV function. Another limitation of our study is that we studied only patients who were able to undergo right-sided cardiac catheterization at the time of admission. Thus, we had to exclude patients who died during the tirst 48 hours. One has to be cautious when considering only the description of a right atrial pressure pattern for the diagnosis of RV involvement. In fact, the presence of a noncompliant pattern on right atrial pressure was present throughout the duration of hemodynamic monitoring in only 23% of patients studied by Lopez-Sendon et al. l3 We believe that in such cases, a combined index could help to recognize RV involvement in a more “objective” way. Finally, the data were obtained in a selected group of patients with inferior wall LV acute myocardial infarction, with no history of previous heart failure or myocardial infarction. Thus, the hemodynamic results presented in this report can only be applied to this group of patients. .

Clinical implications: Our series appears to be the largest published clinical series studying the value of hemodynamic parameters for the diagnosis of RV involvement in selected patients consecutively admitted for inferior wall LV acute myocardial infarction. The right atria1 pressure noncompliant pattern, isolated or associated with a disproportionate elevation of the right-sided heart filling pressures compared with pulmonary capillary wedge pressure, appears to be the parameter with the best diagnostic value. Based on such a definition, volume loading did not have any additional diagnostic value.

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hemodynamic criteria for diagnosis of right ventricular ischemia associated with inferior wall left...

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