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cardio.stemi.right-ventricular.v1

Right-ventricular extension STEMI (proximal RCA)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.stemi.core.v1 — narrowed to right-ventricular extension of inferior STEMI (proximal RCA culprit). Inherits reperfusion + antiplatelet + statin regimen from parent via routing; specializes HEMODYNAMIC management — preload-dependent state requiring volume loading, dobutamine for refractory hypotension, and explicit Class III avoidance of nitrates/diuretics/morphine (AHA 2025). Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (RV-specific differences documented inline, anchored to Kinch & Ryan NEJM 1994 PMID 8208270). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as part of Phase E variant batch (inferior/RV/posterior/LMCA).

Entry points (3)

  • imaging
    V4R ST↑ ≥1 mm + inferior ST↑ II/III/aVF (RV-extension STEMI, proximal RCA)
    ecg_v4r_st_elevation_with_inferior
  • symptom
    Inferior STEMI + hypotension + clear lung fields + JVP elevation → presumptive RV extension; obtain V4R immediately
    inferior_stemi_with_hypotension_clear_lungs
  • history
    Routed from cardio.stemi.inferior.v1 after V4R+ confirmed
    inferior_stemi_referred_from_inferior_engine

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older patients with RV extension have higher mortality + decompensation risk
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is the cardinal feature of RV-extension; preload-dependent state — fluid-responsive
  • jvprequired
    vital • used at RED_FLAGS
    Elevated JVP + clear lungs + hypotension = classic RV infarct triad (Kinch & Ryan PMID 8208270)
  • ecg_v4rrequired
    imaging • used at INITIAL_WORKUP
    V4R ST↑ ≥1 mm = RV extension; obtained as Class I in all inferior STEMI per AHA 2025
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Inferior ST↑ II/III/aVF; ST↑ III > II + V1 ST↑ supports proximal RCA culprit
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Confirms infarct; RV troponin elevation typically modest given smaller mass than LV
  • creatininerequired
    lab • used at CONTEXT
    Contrast nephropathy risk + dosing
  • echo_post_pcirequired
    imaging • used at MONITORING
    RV size + function + TAPSE; confirm RV dilation/hypokinesis; assess for IVC plethora
  • cor_angiorequired
    imaging • used at TREATMENT
    Proximal RCA culprit confirmation (lesion proximal to RV-marginal branches)

12-phase flow (10)

  1. 1FRAME
    RV-extension STEMI = proximal RCA culprit (lesion proximal to RV-marginal branches); ≈30-40% of inferior STEMIs have some RV involvement; preload-dependent hemodynamics dominate management — distinct from LV-dominant STEMI; route to cardio.stemi.core.v1 for the reperfusion arc
    inputs: ecg_v4r
    advance: V4R+ confirmed
  2. 2ENTRY
    Cath lab within 90 min; bedside echo for RV size + function + TAPSE; IV access × 2 for fluid loading
    inputs: age, sbp
    advance: cath lab activated + IV access secured
  3. 3CONTEXT
    Allergies, bleed risk, recent surgery, antithrombotic regimen; medication reconciliation — STOP home nitrates, diuretics, morphine if recently administered
    inputs: sbp, creatinine, jvp
    advance: context complete; preload-reducer meds discontinued
  4. 4RED_FLAGS
    Hypotension management (the dominant clinical problem); cardiogenic shock screen (RV-CS distinct from LV-CS); arrhythmias from atrial stretch (AF common with RV failure); concurrent inferior MI complications; preload optimization (NS 1-2L bolus, then dobutamine if persistent); STOP nitrates/diuretics/morphine (Class III AHA 2025)
    inputs: sbp, jvp
    actions: cardiogenic_shock
    advance: hemodynamic strategy in place
  5. 5INITIAL_WORKUP
    ECG + V4R + troponin + BMP + CBC + CXR + bedside echo (RV size, function, TAPSE, IVC, LV function, valvular)
    inputs: ecg, ecg_v4r, troponin, creatinine, echo_post_pci
    actions: acs_pathway, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Primary PCI of proximal RCA; preserve RV-marginal branches if possible; complete revasc per COMPLETE if multivessel
    inputs: cor_angio
    advance: reperfusion delivered
  7. 7TREATMENT
    Standard ACS regimen (ASA + ticagrelor + UFH + statin) per cardio.stemi.core.v1; CRITICAL: AVOID nitrates, diuretics, morphine (Class III AHA 2025 — preload reduction in preload-dependent state causes cardiovascular collapse); volume-load with NS 1-2L bolus then assess; dobutamine for persistent hypotension despite volume; defer BB until RV-failure resolves
    inputs: sbp, jvp, creatinine
    actions: protocol.stemi
    advance: reperfusion + hemodynamic strategy + bundle initiated
  8. 8DISPOSITION
    CICU mandatory; RV failure can decompensate quickly
    advance: CICU bed assigned + hemodynamic plan documented
  9. 9MONITORING
    CICU telemetry + arterial line if hypotension; serial echo for RV recovery (most RV function recovers within days-weeks of reperfusion); avoid preload reducers throughout admission
    inputs: echo_post_pci
    actions: panel.cardiac
    advance: RV recovering + BP stable off vasopressors
  10. 10FOLLOWUP
    Cardiology follow-up; echo at 30 d for RV recovery confirmation; cardiac rehab (caution with diuretic prescription if persistent RV dysfunction)
    advance: cardiac rehab booked + RV function reassessed