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 Table of Contents  
ORIGINAL RESEARCH
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 108-115

Echocardiographic Evaluation of Right Ventricular Function in Patients Presenting with Acute ST-Elevation Myocardial Infarction


Department of Cardiology, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission26-Aug-2021
Date of Acceptance01-Dec-2021
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Rajneesh Kumar Calton
Department of Cardiology, Christian Medical College and Hospital, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_52_21

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  Abstract 

Background: To evaluate the effect of different infarction sites on the right ventricular (RV) function by echocardiography in patients presenting with acute ST-elevation myocardial infarction (STEMI) and to correlate it with in-hospital morbidity and mortality. Materials and Methods: The present study was a descriptive cross-sectional study conducted in a tertiary care hospital involving 55 patients of anterior wall myocardial infarction (AWMI), 25 patients of inferior wall myocardial infarction (IWMI), and 20 patients of IWMI + RVMI. Among them, 55% of patients were males with a M: F ratio of 1.22:1. M-mode, two-dimensional, and Doppler echocardiographic evaluation of both RV and left ventricular (LV) function (tricuspid annular plane systolic excursion/RV fractional area change/right ventricular index of myocardial performance and LV ejection fraction [LVEF]) were done in all patients within 48 h of admission along with the assessment of arrhythmias, heart failure (HF), cardiogenic shock (CS), and complete heart block (CHB). All the four echocardiographic parameters were deranged in 30 (54.5%) patients of AWMI and 14 (70%) patients of IWMI with RVMI. However, derangement in at least one echocardiographic parameter of RV dysfunction was observed in 50 (90.9%) patients of AWMI, 11 (44%) patients of IWMI, and 20 (100%) patients of IWMI+RVMI, respectively. LVEF was significantly reduced in patients with AWMI (40.4 ± 11.2%) as compared to patients with IWMI and IWMI+RVMI, respectively (46.4 ± 10.3% and 46.5 ± 7.6%). Cardiovascular complications (ventricular tachycardia, ventricular fibrillation, atrial fibrillation, CS, and HF) were more in the AWMI patients with RV dysfunction. HF was specifically more in the patients of AWMI (81.8%) than IWMI (28%) and IWMI+RVMI (20%). CHB was frequently seen in IWMI (20%) and IWMI+RVMI (20%) patients. Conclusion: RV dysfunction is not only common in RVMI but also in AWMI and IWMI, and complications of STEMI are also more frequently seen in patients with RV dysfunction.

Keywords: Anterior wall myocardial infarction, inferior wall myocardial infarction, right ventricular dysfunction, right ventricular myocardial infarction, ST-elevation myocardial infarction


How to cite this article:
Gupta RK, Shahi RS, Calton RK. Echocardiographic Evaluation of Right Ventricular Function in Patients Presenting with Acute ST-Elevation Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:108-15

How to cite this URL:
Gupta RK, Shahi RS, Calton RK. Echocardiographic Evaluation of Right Ventricular Function in Patients Presenting with Acute ST-Elevation Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2022 Oct 5];6:108-15. Available from: https://jiaecho.org/text.asp?2022/6/2/108/354321




  Introduction Top


Acute myocardial infarction (MI) is characterized by abrupt cessation of blood flow with loss of contractile tissue and change in ventricular geometry that causes a substantial impairment of the left ventricular (LV) and right ventricular (RV) systolic and diastolic function. RV dysfunction may be primarily attributed to an abnormality of RV myocardium or secondary to LV dysfunction as a consequence of “ventricular interdependence” between the two ventricles.[1] RV dysfunction is a powerful risk marker after MI.[2] RV functional parameters have independent and additive prognostic implications in patients with LV dysfunction.[3] RV involvement after an MI has been shown to be associated with higher morbidity and mortality.[4]

Nearly 50% of the patients with inferior wall myocardial infarction (IWMI) and 10% or fewer patients with anterior wall myocardial infarction (AWMI) have evidence of RV involvement.[5],[6] RV function in LV anterior infarction has been the subject of several studies but with significant discrepancies in the findings.[1],[7],[8] The prevalence of RV involvement in MI has been reported to range from 50% to 80% in postmortem studies.[9] Historically, the echocardiographic assessment of diseases affecting the RV has lagged behind that of the LV, despite knowledge demonstrating that diseases affecting the right heart have the same clinical consequences as those affecting the left heart.[10],[11],[12],[13]

Aims and Objectives

The aim of this study was to evaluate the effect of different MI sites on RV function as assessed by echocardiography, in patients presenting with acute ST-elevation myocardial infarction (STEMI), and to correlate with in-hospital morbidity and mortality.


  Materials and Methods Top


The present study was a descriptive cross-sectional study of STEMI patients conducted at a tertiary care hospital over a period of 1 year from June 1, 2019, to May 31, 2020.

Inclusion criteria

All patients above 18 years of age presenting with acute STEMI were included in the study.

Exclusion criteria

  1. Patients with prior history of MI
  2. Patients with prior angioplasty, stenting, or cardiac surgery
  3. Bundle branch block and other intraventricular conduction delay
  4. Preexisting valvular heart disease
  5. Patients with known pulmonary hypertension.


Methodology

All patients were subjected to detailed history taking with special emphasis on risk factors of coronary artery disease (CAD) such as diabetes mellitus, hypertension, obesity, smoking, dyslipidemia, and positive family history of premature CAD. Resting 12-lead surface electrocardiogram (ECG) including V4R, V5R, and V6R leads was recorded in all patients.[14],[15] On the basis of ECG criteria, all MI patients were divided into the following groups-

Group I- Patients with AWMI

Group II (a)- Patients with IWMI

Group II (b)- Patients with IWMI with RVMI.

  • Two-dimensonal (2D) and Doppler echocardiographic evaluation of both RV and LV function (tricuspid annular plane systolic excursion (TAPSE)/RV fractional area change (FAC)/right ventricular index of myocardial performance/ Doppler tissue imaging (DTI) derived tricuspid lateral annular systolic velocity and LV ejection fraction [LVEF]) were done in all patients according to the 2015 recommendations of the American Society of Echocardiography within 48 h of admission.[16]


Echocardiographic parameters

  • TAPSE: In the apical four-chamber view using M-mode, tricuspid annuluar systolic displacement was measured as the vertical distance from the R-wave on the electrocardiogram to its peak excursion. TAPSE <17 mm was used as an indicator of RV systolic dysfunction [Figure 1]a
  • RV FAC was calculated from the RV focussed apical four-chamber view as the percentage change in RV area between end-diastole and end-systole. RV FAC % = (RV end-diastolic area – RV end-systolic area)/RV end-diastolic area × 100
  • Figure 1: (a) Measurement of tricuspid annular plane systolic excursion. (b) Quantification of the right ventricle systolic function by measuring fractional area change. The right ventricular area is measured in end-diastole and end-systole. (c) Calculation of myocardial performance index of the right ventricle by tissue Doppler imaging. (d) Measurement of systolic tissue velocity of tricuspid lateral wall annulus S'
    ET: Ejection time; FAC: Fractional area change; IVCT: Isovolumic contraction time; IVRT: Isovolumic relaxation time; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RIMP: Right ventricular index of myocardial performance; RV: Right ventricle; RVAd: Right ventricular area in diastole; RVAs: Right ventricular area in systole


    Click here to view


    RV FAC <35% was considered abnormal [Figure 1]b

  • RV myocardial performance index (MPI) was assessed by measuring isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT), and ejection time (ET) from the same heartbeat using tissue Doppler imaging (TDI) velocity of the lateral tricuspid annulus


  • Myocardial performance index (MPI) = IVCT + IVRT/ET

    MPI >0.54 by TDI was considered a marker of RV dysfunction [Figure 1]c

  • Systolic tissue velocity of tricuspid lateral wall annulus: The peak systolic tricuspid lateral annular velocity (S') was measured using pulsed-wave TDI. Velocity <9.5 cm/s was considered abnormal [Figure 1]d.


The patients were also evaluated for various in-hospital outcomes, including arrhythmias, complete heart block (CHB), heart failure (HF) and cardiogenic shock (CS). Arrhythmias (atrial fibrillation/atrial flutter/ventricular tachycardia/ventricular fibrillation were defined as per 2017 and 2019 American College of Cardiology/ American Heart Association guidelines.[17],[18] Heart failure (HF) is a clinical syndrome characterized by typical symptoms e.g. breathlessness, ankle swelling and fatigue. It may be accompanied by signs such as elevated jugular venous pressure, pulmonary crackles and peripheral oedema caused by a structural and/or functional cardiac abnormality. It results in reduced cardiac output and/ or elevated intracardiac pressures at rest or during stress. It may or may not be accompanied by LV systolic dysfunction, with reduced LVEF typically considered as <40%.[19] CS is defined as sustained hypotension with systolic blood pressure <90 mmHg for more than 30 minutes or requiring vasopressors to achieve a systolic blood pressure >90 mmHg with pulmonary congestion or elevated left ventricular filling pressures with signs of impaired organ perfusion.[20]

Statistical analysis

Data were recorded, and the Statistical Product And Service Solutions v 23 (International Business Machines Corporation, Armonk, New York, USA) was used for data analysis. Descriptive statistics were presented in the form of means/standard deviations. Group comparisons for continuously distributed data were made using independent sample t-test when comparing two groups. Appropriate nonparametric tests in the form of Wilcoxon test were used. Chi-square test was used for group comparisons for categorical data. In case the expected frequency was <5 in the contingency tables, Fisher's exact test was used. Linear correlation between two continuous variables was explored using Pearson's correlation (if the data were normally distributed) and Spearman's correlation (for nonnormally distributed data). Statistical significance was kept at P < 0.05.


  Results Top


The present study consisted of 55, 25, and 20 patients of AWMI, IWMI, and IWMI + RVMI, respectively [Figure 2]. The mean age in the AWMI, IWMI, and IWMI + RVMI groups was 59.0 (±8.95), 59.8 (±10.00), and 58.0 (±10.04) years, respectively, with 29 patients of AWMI, 15 patients of IWMI, and 11 patients of IWMI + RVMI being males. Diabetes was present in 52.7% of the AWMI, 36.0% of IWMI, and 85% of IWMI + RVMI patients. Hypertension was present in 47.3% of patients of AWMI, 28% of patients of IWMI, and 60% of patients of IWMI + RVMI, respectively. Family history of CAD was present in 34.5% of AWMI, 28% of IWMI, and 20% of IWMI with RVMI patients, respectively. In addition, 25.5% of the AWMI, 32% of the IWMI, and 40% of the IWMI + RVMI patients were smokers. Dyslipidemia was present in 33 (60%) patients of AWMI, 21 patients (84%) of IWMI, and 10 (50%) patients of IWMI + RVMI, respectively [Figure 3] and [Table 1].
Figure 2: Distribution of patients with AWMI, IWMI and IWMI with RVMI
AWMI: Anterior wall myocardial infarction; IWMI Inferior wall myocardial infarction; RVMI: Right ventricular myocardial infarction


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Figure 3: Clinical characteristics of patients with AWMI, IWMI and IWMI with RVMI. Age is in years whereas other values represent proportions
AWMI: Anterior wall myocardial infarction; CAD: Coronary artery disease; DM: Diabetes mellitus; HT: Hypertension; IWMI: Inferior wall myocardial infarction; RVMI: Right ventricular myocardial infarction


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Table 1: Baseline characteristics of the patients in the three myocardial infarction groups

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Echocardiographic parameters

Myocardial performance index

The IVCT in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 66.0 (±10.73), 66.4 (±9.50), and 63.3 (±5.00) milliseconds, respectively, with no significant difference among the groups. The IVRT in patients presenting with AWMI, IWMI, and IWMI + RVMI was 76.7 (±11.27), 68.0 (±8.80), and 70.2 (±7.50) milliseconds, respectively, with statistically significant difference between patients with AWMI and those with IWMI (P = 0.003). The ET in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 242.3 (±21.96), 259.3 (±23.69), and 232.0 (±15.24) milliseconds, respectively. Pairwise comparison of ET between AWMI versus IWMI and IWMI + RVMI versus IWMI patients was found to be statistically significant (P = 0.004 and < 0.001). There was a significant difference between the three groups in terms of MPI (P ≤ 0.001), with the MPI being highest in the patients with AWMI. MPI in the patients with AWMI, IWMI, and IWMI with RVMI was 0.58 (±0.04), 0.51 (±0.05), and 0.57 (±0.01), respectively. The differences were statistically significant for patients presenting with AWMI versus IWMI and IWMI + RVMI versus IWMI (P < 0.001) [Table 2] and [Table 3] and [Figure 4].
Table 2: Various echocardiographic parameters in the three myocardial infarction groups

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Table 3: Pairwise comparison of various echocardiographic parameters in the three myocardial infarction groups

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Figure 4: Echocardiographic parameters and left ventricular ejection fraction in patients with anterior wall myocardial infarction, inferior wall myocardial infarction, and inferior wall myocardial infarction with right ventricular myocardial infarction
AWMI: Anterior wall myocardial infarction, FAC: Fractional area change, IWMI: Inferior wall myocardial infarction, LVEF: Left ventricular ejection fraction, MPI: Myocardial performance index, RVMI: Right ventricular myocardial infarction, S': Tricuspid annular systolic velocity, TAPSE: Tricuspid annular plane systolic excursion


Click here to view


Tricuspid systolic lateral annular velocity (S')

The S' in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 8.86 cm/s, 10.24 cm/s, and 8.36 cm/s, respectively. Pairwise comparison of S' between AWMI versus IWMI and IWMI + RVMI versus IWMI was found to be statistically significant (P < 0.001) [Table 2] and [Table 3] and [Figure 4].

Right ventricular fractional area change

The RV end-diastolic area in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 16.31 cm2 (±3.52), 16.12 cm2 (±4.74), and 14.75 cm2 (±2.42), respectively. The RV end-systolic area in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 11.12 cm2 (±3.12), 10.01 cm2 (±2.94), and 10.08 cm2 (±1.87), respectively. The FAC in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 32.91% (±5.99), 38.43% (±10.69), and 31.76% (±3.73), respectively. The differences were statistically significant for comparison of AWMI with IWMI and IWMI + RVMI with IWMI (P < 0.001) [Table 2] and [Table 3] and [Figure 4].

Tricuspid annular plane systolic excursion

The TAPSE in the patients presenting with AWMI, IWMI, and IWMI + RVMI was 14.40 mm (1.97), 16.97 mm (3.39), and 13.40 mm (2.02), respectively. Pairwise comparison of TAPSE between AWMI versus IWMI and IWMI + RVMI versus IWMI was found to be statistically significant (P < 0.001) [Table 2] and [Table 3] and [Figure 4].

Left ventricular ejection fraction

There was a significant difference between the three groups in terms of LVEF (P = 0.016) with the median LVEF being lowest in AWMI group. The LVEF in the patients with AWMI, IWMI, and IWMI + RVMI was 40.36% (±11.22), 46.40% (±10.26), and 46.50% (±7.63), respectively [Table 2] and [Table 3] and [Figure 4].

There was a significant difference between the various groups in terms of distribution of all four RV dysfunction parameters (P ≤ 0.001). Thirty (54.5%) patients in the AWMI group and 14 (70%) patients in the IWMI + RVMI group had all four RV function parameters abnormal. However, no patients in the IWMI group fulfilled all the echocardiographic criteria for RV dysfunction. The pairwise comparison of RV dysfunction in patients with AWMI versus IWMI and IWMI + RVMI versus IWMI was found to be statistically significant (P < 0.001). At least, one RV dysfunction parameter was deranged in 50 (90.9%) patients in AWMI, 11 (44%) patients in IWMI, and 20 (100%) patients in IWMI + RVMI, respectively [Table 4] and [Figure 5].
Table 4: Distribution of number of right ventricular dysfunction parameters in the three myocardial infarction groups

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Figure 5: Distribution of the number of right ventricular dysfunction parameters in patients with AWMI, IWMI and IWMI with RVMI
AWMI: Anterior wall myocardial infarction; IWMI Inferior wall myocardial infarction; RVMI: Right ventricular myocardial infarction


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Cardiac complications

In the present study, there was no significant difference between the patients in AWMI, IWMI, and IWMI + RVMI groups in terms of CS (P = 0.243). There was no significant difference between the various groups in terms of incidence of ventricular tachycardia (P = 0.347) and ventricular fibrillation (P = 1.000). Furthermore, there was no significant difference between AWMI, IWMI, and IWMI + RVMI patients in terms of occurrence of atrial fibrillation (P = 0.872). However, there was a significant difference among the three groups in terms of occurrence of CHB (P = 0.005). Patients with IWMI or IWMI + RVMI both had much higher incidence of CHB as compared to the patients with AWMI (P = 0.024). There was a significant difference between AWMI, IWMI, and IWMI + RVMI patients in terms of distribution of HF (P ≤ 0.001). A total of 81.8% patients of AWMI, 28.0% patients of IWMI, and 20.0% patients of IWMI + RVMI had HF, respectively. Pairwise comparison of HF in patients with AWMI versus IWMI and IWMI + RVMI versus AWMI groups was found to be statistically significant [Table 5] and [Figure 6].
Table 5: Distribution of cardiac complications in the three myocardial infarction groups

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Figure 6: Various cardiac complications in patients who met all four echocardiographic criteria of RV dysfunction.
AF: Atrial fibrillation; AWMI: Anterior wall myocardial infarction; CHB: Complete heart block; CS: Cardiogenic shock; HF: Heart failure; IWMI Inferior wall myocardial infarction; RV: Right ventricular; RVMI: Right ventricular myocardial infarction; VF: Ventricular fibrillation; VT: Ventricular tachycardia


Click here to view


In the present study, patients of AWMI having RV dysfunction according to all four echocardiographic parameters had a higher incidence of CS, ventricular tachycardia, ventricular fibrillation, atrial fibrillation, and HF in comparison to the patients of AWMI without RV dysfunction. However, this increase in complications was not statistically significant. In the IWMI and the IWMI + RVMI groups, the incidence of CHB was more.


  Discussion Top


LV function is a known predictor of cardiovascular morbidity and mortality after MI.[21] RV dysfunction has been associated with an adverse outcome in patients with HF and may be secondary to long-term exposure of the RV to chronic elevation of the left-sided pressures. In the present study, the age of the patients ranged from 40 to 90 years, with the majority (69%) being in middle-aged and elderly groups. Dyslipidemia was found to be the most common risk factor which was present in 64% of patients whereas smoking was seen least commonly in 30% of patients.

Echocardiographic parameters of RV systolic functions were found to be significantly deranged. All the four echocardiographic parameters of RV function (TAPSE/FAC/MPI/S') were abnormal in 30 (54.5%) patients of AWMI and 14 (70%) patients of IWMI + RVMI. No patients presenting with IWMI had all four echocardiographic parameters deranged. However, derangement in at least one echocardiographic parameter of RV function was observed in 90.9% patients of AWMI, 44% patients of IWMI, and 100% patients of IWMI + RVMI, respectively. Thus, RV dysfunction was more commonly seen in IWMI + RVMI patients followed by AWMI patients. AWMI patients revealed more RV dysfunction than the patients presenting with IWMI. Abtahi et al. have also demonstrated that both anterior and inferior infarction had marked effects on RV function, and RV MPI was significantly higher in the patients with anterior infarction compared to those with inferior infarction.[22] Jensen et al. also reported RV involvement in 47% of patients with inferior infarction and 65% of those with anterior infarction using cardiac magnetic resonance imaging.[23] Aher et al. demonstrated that AWMI resulted in more RV dysfunctional changes, both systolic and global, as compared with IWMI and RV dysfunction might cause more major adverse cardiac events after acute MI.[24] Abdeltawab et al. assessed RV function in 40 patients who underwent primary percutaneous coronary intervention for the first acute anterior STEMI without RV infarction and found that 55% of the patients had RV dysfunction, defined as a combination of at least two of the following- TAPSE <16 mm, RV FAC <35%, RVMPI using TDI >0.55.[25]

In the present study, TAPSE was maximally reduced (13.40 ± 2.02 mm) in IWMI + RVMI patients followed by AWMI (14.40 ± 1.97 mm) and IWMI (16.97 ± 3.39 mm) patients, respectively. In a previous study, Adilakshmi and Pakira had shown that systolic TAPSE was significantly lower in patients with inferior MI (20.5 ± 5 mm) as well as anterior MI (23 ± 4 mm) compared to healthy controls (27 ± 4 mm, P < 0.001).[26] Roopesh et al. in their study had shown that TAPSE was deranged in 30.3% patients of AWMI and 34.2% patients of IWMI.[27] Akdemir et al. investigated RV performance of patients with a first AWMI and found that TAPSE was significantly lower (P < 0.001) and E' of RV free wall (P = 0.011) significantly increased in AWMI group.[28]

In our study, MPI was abnormal in 40 (72.7%) patients of AWMI, 3 (12%) patients of IWMI, and 17 (85%) patients of IWMI + RVMI. However, the absolute value of MPI was maximum (0.58 ± 0.04) in AWMI patients followed by IWMI + RVMI (0.57 ± 0.01) and IWMI (0.51 ± 0.05) patients. Møller et al. demonstrated that an abnormal RV MPI was present in 80% of patients with MI.[29] Hsu et al. also revealed that RV MPI was significantly higher in anterior MI than in inferior MI.[30] Abtahi et al. also showed abnormal RV MPI in AWMI.[22]

Systolic tricuspid lateral annular velocity S' was significantly reduced in 42 (76.4%) patients of AWMI, 4 (16%) patients of IWMI, and 20 (100%) patients of IWMI + RVMI. However, S' was maximally reduced (8.36 ± 0.80 cm/s) in IWMI + RVMI patients followed by AWMI (8.86 ± 1.67 cm/s) and IWMI (10.24 ± 1.09 cm/s) patients. Similar findings were reported in other studies Alam et al.[31] and Ozdemir et al.[32]

RV FAC was also significantly reduced in 38 (69.1%) patients of AWMI, 2 (8%) patients of IWMI, and 17 (85%) patients of IWMI + RVMI, respectively. Adilakshmi and Pakira had also found RV FAC to be more abnormal in AWMI than IWMI.[26] Antoni et al. found that RV FAC was a strong predictor of the composite endpoint of all-cause mortality, reinfarction, and hospitalization for HF.[33]

Thus, the present study reveals that RV dysfunction occurs in patients presenting with acute STEMI, and it is more pronounced in patients of AWMI and IWMI + RVMI than IWMI. LVEF was significantly more reduced in patients with AWMI (40.36 ± 11.22%) than in the patients of IWMI and IWMI + RVMI, respectively (46.40 ± 10.26% and 46.50 ± 7.63%). Moreover, the incidence of cardiovascular complications was more common in AWMI patients with RV dysfunction in comparison with the IWMI group. HF was specifically more common in patients of AWMI (81.80%) in comparison to the patients of IWMI (28%) and IWMI + RVMI (20%). However, CHB was more seen in IWMI (20%) and IWMI + RVMI (20%) patients.

Limitations

This study was carried out in 100 patients which is a small sample size. The cut-off values of echocardiographic parameters to define RV dysfunction have been derived from the Western populations and may not be applicable to the Indian patients. Furthermore, RV function assessed by 2D echocardiography/Doppler study was not compared with cardiac magnetic resonance imaging, which is considered a better modality and the gold standard for evaluation of RV function. Interobserver variability in the measurement of various echocardiographic parameters cannot be ruled out. Finally, only the in-hospital outcomes were studied, and the postdischarge follow-up was not a part of the study.


  Conclusion Top


The present study shows that AWMI results in more RV dysfunctional changes in comparison to IWMI. Complications of myocardial infarction are seen more in patients with RV dysfunction, and this leads to prolongation of the hospital stay as well as increased morbidity and mortality. The present study suggests that the assessment of echocardiographic parameters of RV function should be done routinely in all the patients of acute STEMI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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