Pulmonary Embolus versus Right Ventricular Infarction

OVERVIEW

  • features that distinguish PE from RV infarction

COMPARISON TABLE

Table created by Chris Poynter

123
RV infarctAcute PE
History
  • Known IHD or family history
  • Previous MI
  • Diabetes
  • Smoker
  • Hypercholesterolaemia
  • Hypertension
  • Related to Virchow triad:
  • – venous stasis
  • – vessel injury
  • – hypercoagulability
Eg. Immobility, obesity, surgery, trauma, fractures, pregnancy, drugs eg. OCP, malignancy
symptoms
  • Cardiac chest pain eg. Central with radiation to jaw/arm
  • Can be atypical e.g. epigastric, back pain
  • +/- N&V, sweating, collapse, SOB
  • Silent/asymptomatic
  • Usually acute dyspnoea
  • Pleuritic chest pain
  • Haemoptysis/Cough
  • DVT/calf pain or swelling preceding
Examination
  • Lungs more likely to be clear
  • Arrhythmias common — esp bradyarrythmia eg. Complete heart block
  • Diaphoresis
  • Low Pulmonary pressures on PAC
  • Lung crackles/rales
  • Loud P2, Pulmonary hypertension on PAC
  • Cyanosis
  • Fever
  • Tachypnoea, hypoxia/increased FiO2
  • Calf swollen, tender, red
Investigations
bedsideECG – classic inferior/posterior MI changes with ST elevation in inferior leads and V4R, evidence of heart blockECG – Tachycardia, S1Q3T3ABG – hypoxia, increased A-a gradient, hypocapnia
laboratoryRaised troponin, CK, CKMBTroponin may be raised but lesser degree
radiological
  • CXR may be clear
  • Echo – regional wall motion abnormalities, Inferior LV hypokinesis
  • CXR – 80% show abnormailities eg. Pleural effusion, atelectasis, pulm. Infiltrates, Hampton’s hump, Westermark’s sign
  • Echo – evidence of pulmonary hypertension, McConnell’s sign (apical sparing of RV akinesis)
  • CTPA – shows to segmental level which should be adequate if presenting as RV failure
special testsAngiogram – blocked RCA (right dominant)
  • Pulmonary angiogram gold standard for diagnosis
  • V/Q scan may help if other options

References and Links

  • Ginghina C, Caloianu GA, Serban M, Dragomir D. Right ventricular myocardial infarction and pulmonary embolism differential diagnosis–a challenge for the clinician. J Med Life. 2010 Jul-Sep;3(3):242-53. PMC3019007.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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