On physical exam, blood pressure is 90/55 with a pulse of 90. Oxygen saturations are 98% on 2 litres nasal prongs. JVP is elevated and there is peripheral edema. Heart sounds are normal with no murmurs appreciated. Lungs are clear on auscultation.
You review the initial ECG:
You perform a quick bedside cardiac ultrasound, and the subcostal view reveals the following image:
This is an example of an inferior myocardial infarction with RV involvement. The physical exam demonstrating predominately symptoms of right-sided heart failure in combination with an ECG with ST elevation in inferior leads would suggest RV involvement.
The bedside cardiac ultrasound can help in confirming RV dysfunction, which is present in the ultrasound image above. The RV sits inferiorly and anteriorly, therefore in the subcostal view it appears closest to the probe at the top of the screen. As you can see, it is not contracting well during systole which confirms the suspected RV involvement.
It is important to consider RV involvement in patients with an inferior STEMI since these patients are usually preload dependent. This modifies how they are treated, and they more often require intravenous fluids to increase their pre-load as well as the avoidance of medications that cause vasodilation (ie: nitrates). Since the presence of RV involvement changes how these patients are managed, bedside cardiac ultrasound can assist with management.
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