Ginghina C. Mic tratat de cardiologie. Romania: Editura Academiei Romane; Greyson CR. The right ventricle and pulmonary circulation: basic concepts. the Romanian Journal of Cardiology and I are looking forward to your comments and suggestions! Kindest regards, Professor Carmen Ginghina Editor in chief. Eduard Apetrei. “CC Iliescu” Department of Cardiology – A short history. Cardiologie, cazuri comentate si Ilustrate, Eduard Apetrei, Carmen Ginghina.
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It is frequently recognized in medical literature as well as in daily clinical practice that right ventricular myocardial infarction and pulmonary embolism are two of the most challenging clinical pictures to differentiate in cardiology and the treatment, often chosen upon a mixture of clinical suspicion criteria subsequently confirmed by other diagnostic methods, can lead to therapeutic success.
Differential diagnosis is often difficult due to similar clinical picture, unspecific electrocardiographic changes and unspecific biological markers. It is very important to know the risk factors and the associated comorbidities for these two clinical entities in order to be able to interpret them contextually.
In most cases the diagnosis key is the clinical suspicion. Usually in evaluating these cases we are in the position of choosing more complex diagnostic procedures, most likely not available in Emergency Department. In conclusion it is expected from the clinician to use the available methods with a thorough approach to details but in the same time considering the whole clinical picture.
It is frequently recognized in medical literature as well as in daily clinical practice that the right ventricular myocardial infarction RVMI and pulmonary embolism PE are two of the most challenging clinical pictures to differentiate in cardiology and the treatment, often chosen upon a mixture of clinical suspicion criteria subsequently confirmed by other diagnostic methods. They can lead to therapeutic success. Though for some time is has been thought to be less important, RVMI, is actually considered a condition that can lead to a worsening of the whole cardiac function.
Due to the structural and functional characteristics of the right ventricle thin walled chamber with low pressure, low oxygen demand and both systolic and diastolic perfusionit is unusual to have a massive extension of the infarction and an irreversible progress.
More frequently transient systolic dysfunction and reversible myocardial stunning are seen and most of the cases are recovering the right ventricular function in time. In evaluating these cases, in order to differentiate between RVMI and PE we are in the position of choosing more complex diagnostic procedures, most likely not available in the Emergency Department.
The risk factors for myocardial infarction are well known hypertension, dyslipidemia, smoking, diabetes. Half of the patients with RVMI seem to have identified a precipitant factor such as intense physical activity, psychological stress, and post surgical massive blood loss as well as prodromal symptoms. In most cases, the diagnosis key is the clinical suspicion. Clinically, RVMI is frequently associated with inferior or posterior myocardial infarction and presents with:.
An increased awareness must be kept in mind when we are using these elements because, very often they can be masked by volume depletion and the specific signs are usually obvious only after correcting the fluid status. The specific signs identified in patients with PE are not as specific and they are useful to confirm PE only by associating them with the clinical context Table 1.
Clinical symptoms and signs described in pulmonary embolism [ 2 ]. In a classical and systematically approach, patients with RVMI have signs of right heart failure and those cardillogie PE have signs of pulmonary hypertension and only in some cases signs of right heart failure. In patients with clinically suspected PE, the initial clinical evaluation is concomitant with the risk stratification and clinical probability assessment.
That can be estimated by using cardoilogie validated score Geneva, Wells — Table 2 and Table 3 or by global clinical evaluation. Revised Cardilogie Score[ 2 ].
Wells Score [ 2 ]. In almost one third of the patients with both conditions, the electrocardiogram is within normal limits. It is important to remember that in all cases of suspected RVMI right chest leads recording has to be precociously obtained because, very often the ST changes are transient and they are not being recognizable after 24— 48 hours after the onset of the symptoms.
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However, this has low specificity when an anterior left ventricular myocardial infarction is not excluded. Figure 1 [ 1720 ]. Electrocardiography in a case of inferoposterior and right ventricular myocardial infarction: However, we must not forget that the right chest leads ST changes in RVMI can cardiologue masked when a massive left ventricle one is associated.
One study by Lewin and ginghkna. In PE ECG, changes are frequently non—specific and transient and they are less prominent when haemodynamic status is corrected. One study published by Ferrari and co. Sometimes arrhythmias are also present extra systoles, atrial fibrillation.
Figure 2 [ 21 — 24 ]. ECG diagnosis criteria for pulmonary embolism modified from Chou [ 21 ].
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Electrocardiography in a case of pulmonary embolism: As a rule, when a characteristic electrocardiogram is present, it is suggestive of PE, but a normal aspect does not exclude the diagnostic. They reflect the lesion but not ginghima mechanism, and, the raised levels can indicate a myocardial infarction only cardiologle the clinical picture is suggestive for the diagnostic.
Though CK MB is usually not present in the lungs, it was showed that it could be raised in 7. These changes do not exclude PE in patients with thoracic pain or dyspnoea.
GINGHINA mic tratat de cardiologie.pdf
Though they are fibrin specific, raised levels are present in necrotic lesions, neoplasm, inflammatory processes and pregnancy. A normal D—dimer value has a low predictive value for PE and suggests a low probability. These values must be judged in the diagnosis algorithm and the associated clinical probability assessment should be revised by applying valid scores such as Wells or Geneva.
The other laboratory tests such as slightly raised ESR; moderate leucocytosis; raised plasma fibrinogen; raised hematocrit; global hypercoagulative status in the first 48 h from the onset are not specific neither for RVMI nor for PE.
In patients with PE one can also encounter normal AST; raised total LDH and raised iso—enzymes 3,4,5 ; raised total bilirubin and especially indirect bilirubin — in the first 2—3 days from the onset.
Additional laboratory tests can be requested in young patients with RVMI or PE in order to establish their coagulation status.
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In clinical practice, there are markers that are frequently associated with the mortality and the degree of right ventricle dysfunction such as uric acid; natriuretic peptide — pro BNP and NT fraction; norepinephrine; endoteline. Non—specific changes are usually present and they should not be used for diagnosis. In RVMI, the arterial blood ginbhina can be normal but in massive infarction secondary hypoxemia, they can be present due to low cardiac output.
The hypoxemia can be corrected by oxygen—therapy. When oxygen therapy does not correct the hypoxemia in a RVMI, an intra—cardiac right to left shunt should be suspected patent foramen ovale usually being present. When severe hypoxaemia is associated, a massive Cardiologi or a right—to—left shunt is present.
A normal oxygen pressure does not exclude a PE. Low CO2 values can often be present due to hyperventilation associated with a mild degree of respiratory alkalosis. An alveolo—arterial ratio higher than 15—20 is cardiologje more sensitive indicator for PE when compared to the oxygen pressure. The routine chest X—ray has a limited value in the differential diagnosis of the two conditions and the changes are ranging from a normal aspect to specific changes.
Generally, radiographic changes are present in late stages and they are not helpful in the acute management needed in both situations. When the right myocardial infarction is associated with the left ventricle one, a degree of pulmonary stasis may be present due to global systolic impairment. Chest X—ray can bring helpful information in PE when it carxiologie features of pulmonary hypertension. These depend on the dimensions, the site of the embolus and the time past from the onset Table 5.
Both the sensitivity and the specificity of the chest X—ray are low. Chest X—ray findings in PE 2412 — Postero anterior cardiopulmonary radiography in a gijghina with pulmonary embolism: The right cardiac enlargement with a raised cardio—thoracic index and gingihna round cardiac shape can also be found. If a lateral view is a performed, a cardiac shadow moves anteriorly occupying the retro—sternal area. Because of the challenges that the differential diagnosis poses, based on clinical assessment, performing an echocardiogram is very important.
In RVMI, a short parasternal view and an apical incidence that can evaluate all four cardiac chambers and wall motion are of great use. In RVMI, the right cardiac chambers are dilated and they present motion abnormalities. They are usually associated with inferior and posterior left ventricle wall dyskinesia.
Defects in the motion of the interventricular septum can be present during systole paradoxical movement as well as in diastole suggesting high right ventricle pressures with inverted trans—septal pressure gradient. A right ventricle infarction can range from small hypo—kinetic areas to marked, extensive dilatation and systolic dysfunction. Sometimes, a leftward displacement of the interatrial septum can be present in massive right ventricle infarction cardoilogie if an atrial infarction is associated, suggesting right heart increased pressures.
Inferior vena cava dilatation can be present and respiratory variations are usually lacking Figure 4Figure 5 [ 840 — 45 ]. Doppler examination is useful in RVMI, showing, in most of the cases, the presence of a tricuspid valve dysfunction and dilatation. In extensive RVMI, ventricular filling and ejection flows are very slow and they last for almost the entire cardiac cycle. This pattern, similar to that of a vein, indicates that right ventricle pumping function is lost and it is now behaving as a conduit with a passive role.
The complexity of the right ventricular structure makes the evaluation of the ejection fraction difficult. A reliable marker for the right ventricular function is TAPSE tricuspid annular plane systolic excursion as it evaluates the longitudinal cardiac function. This method is particularly useful in RVMI cases. Some of these findings are not characteristic for right myocardial ventricular infarction and can be found in PE as well.
Frequently, right cardiac chambers are dilated in PE, the interventricular septum is flattened or even a leftward displacement is seen creating a D shape left ventricular aspect. A paradoxical movement of the interventricular septum can be found secondary to the right ventricle overloading. Inferior vena cava dilatation without respiratory variations is also present. A distinct pattern of right ventricular systolic dysfunction with right ventricular free wall severe dyskinesia and with normal apical cardiologid is described in PE McConnel sign.
Continuous Doppler echocardiography at the tricuspid valve: Doppler recording indicating tricuspid regurgitation, with an estimated RV-RA gradient of 37mmHg pulmonary embolism. Rarely, intracavitary thrombi can be found in both situations, parietal thrombi in akinetic areas are present in RVMI, while transient thrombi at the level of inferior vena cava, tricuspid valve or atrial septal defect are seen in PE.
Tissue Doppler imaging is useful in determining myocardial velocities and for ventricular function evaluation. In RVMI, the systolic and early diastolic velocities, myocardial velocities for the free right wall are decreased. Tissue Doppler echocardiography can also demonstrate ventricular asynchrony by using septal and left ventricular free wall measurements.
In RVMI, the typical apex—base gradient is inverted and high flow velocities are found at the apex and in the outflow tract. In PE, an increase in myocardial strain—rate is noticed with the decrease of maximal systolic strain indicating a reduction in cardiac output. The profile changes from protomezosystolic cardiollgie telesystolic and even protodiastolic postsystolic shortening [ 42 — 43 ].
Tissue Doppler cardiologiee to measure the myocardial strain in a case cardiolotie pulmonary embolism: Tissue Doppler echocardiography in a case of pulmonary embolism: Other sonographic imaging techniques transesophageal echocardiography, intravascular ultrasound are used in special situations where the clinical suspicion for a PE is high and when the diagnosis cannot be confirmed by other techniques.
Radionuclide ventriculography is useful in investigating myocardial infarction as it allows the evaluation of ventricular finghina, segmental wall motion and ejection fraction.
In RVMI, ginghona is an evident significant dilatation with motion abnormalities at the level of right ventricle free wall, especially in the apical area, with a reduced ejection cardologie.