This handout is for right-ventricular extension stemi (proximal rca). Your care team identified this based on: v4r st↑ ≥1 mm + inferior st↑ ii/iii/avf (rv-extension stemi, proximal rca).
Other reasons your team may use this plan: inferior stemi + hypotension + clear lung fields + jvp elevation → presumptive rv extension; obtain v4r immediately; routed from cardio.stemi.inferior.v1 after v4r+ confirmed.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| aspirin | 162-325 mg chewed | PO | load + 81 mg daily | ACC/AHA 2025 ACS Class I; same as parent |
| ticagrelor | 180 mg load → 90 mg BID | PO | BID × 12 mo default DAPT | PLATO PMID 19717846; same as parent |
| normal saline | 500-1000 mL bolus, repeat to total 1-2L | IV | titrated to BP/JVP/lung exam | Preload-dependent state — volume loading is first-line for hypotension; Kinch & Ryan PMID 8208270; AHA 2025 Class I |
| dobutamine | 2-10 mcg/kg/min IV | IV | continuous infusion | Inotropic support for RV failure unresponsive to volume; AHA 2025 Class IIa |
| nitroglycerin | CONTRAINDICATED — Class III AHA 2025 | IV/SL | avoid | AHA 2025 Class III — preload reduction in preload-dependent state causes profound hypotension/collapse; avoid throughout RV-extension management — encoded as contraindication_substitute (this phenotype substitutes volume-loading for nitrate-based preload reduction) |
| furosemide | CONTRAINDICATED in acute RV-extension | IV | avoid | AHA 2025 Class III — diuresis reduces preload, causes RV-CO collapse; can be used cautiously after RV recovery if pulmonary edema develops from concurrent LV dysfunction — encoded as contraindication_substitute (avoid in acute RV phenotype) |
| morphine | AVOID — venodilator + sympathetic blunting | IV | avoid | Venodilation reduces preload; also blunts sympathetic compensation; AHA 2025 caution; use fentanyl alternative for pain if essential — encoded as contraindication_substitute (fentanyl substitutes for morphine in this phenotype) |
Plan: RV-extension STEMI hemodynamic phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen; dominated by preload-dependence
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiology follow-up; echo at 30 d for RV recovery confirmation; cardiac rehab (caution with diuretic prescription if persistent RV dysfunction)
Guideline: 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + Kinch & Ryan NEJM 1994