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cardio.stemi.right-ventricular.v1PRODUCTION
cardio.stemi.right-ventricular.v1

Right-ventricular extension STEMI (proximal RCA)

cardiologyacuteadult
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10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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V4R+ confirmed

Patient inputs (9)

Older patients with RV extension have higher mortality + decompensation risk

Contrast nephropathy risk + dosing

V4R ST↑ ≥1 mm = RV extension; obtained as Class I in all inferior STEMI per AHA 2025

Inferior ST↑ II/III/aVF; ST↑ III > II + V1 ST↑ supports proximal RCA culprit

Confirms infarct; RV troponin elevation typically modest given smaller mass than LV

RV size + function + TAPSE; confirm RV dilation/hypokinesis; assess for IVC plethora

Hypotension is the cardinal feature of RV-extension; preload-dependent state — fluid-responsive

Elevated JVP + clear lungs + hypotension = classic RV infarct triad (Kinch & Ryan PMID 8208270)

Proximal RCA culprit confirmation (lesion proximal to RV-marginal branches)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateningrv_extension_with_hypotension_unresponsive_to_volume
    V4R+ inferior STEMI + SBP <90 not responsive to NS 1-2L bolus
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrv_extension_with_inadvertent_preload_reducer
    Patient received nitrate, diuretic, or morphine prior to V4R recognition; profound hypotension developed
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererv_extension_with_high_grade_av_block
    V4R+ + 2°-3° AV block (often coexists in proximal RCA lesions affecting AV-node supply)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterv_extension_with_atrial_fibrillation
    New AF in V4R+ inferior STEMI from atrial stretch due to RV failure / elevated RA pressure
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

RV-extension STEMI hemodynamic phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen; dominated by preload-dependence
axis: rv_extension_stemi_hemodynamic_phenotype
Selected axis "RV-extension STEMI hemodynamic phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen; dominated by preload-dependence" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed • PO • load + 81 mg daily
    triggers: stemi_post_rosc
    ACC/AHA 2025 ACS Class I; same as parent
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo default DAPT
    triggers: stemi_pci_planned
    PLATO PMID 19717846; same as parent
    rxcui 1116632
  • normal saline
    first line
    crystalloid
    500-1000 mL bolus, repeat to total 1-2L • IV • titrated to BP/JVP/lung exam
    triggers: rv_extension_with_hypotension
    Preload-dependent state — volume loading is first-line for hypotension; Kinch & Ryan PMID 8208270; AHA 2025 Class I
    rxcui 9863
  • dobutamine
    rescue
    inotrope_beta1_selective
    2-10 mcg/kg/min IV • IV • continuous infusion
    triggers: rv_extension_with_persistent_hypotension_post_volume
    Inotropic support for RV failure unresponsive to volume; AHA 2025 Class IIa
    rxcui 3616
  • nitroglycerin
    contraindication substitute
    nitrate
    CONTRAINDICATED — Class III AHA 2025 • IV/SL • avoid
    triggers: rv_extension_confirmed
    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)
    rxcui 4917
  • furosemide
    contraindication substitute
    loop_diuretic
    CONTRAINDICATED in acute RV-extension • IV • avoid
    triggers: rv_extension_confirmed
    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)
    rxcui 4603
  • morphine
    contraindication substitute
    opioid_pain
    AVOID — venodilator + sympathetic blunting • IV • avoid
    triggers: rv_extension_confirmed
    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)
    rxcui 7052

outpatient playbook — drug actions (1)

  1. 1. continue secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + BB • PO • as scheduled
    trigger: post-RV-MI
    AHA 2025

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: V4R ST↑ ≥1 mm + inferior ST↑ II/III/aVF (RV-extension STEMI, proximal RCA); Inferior STEMI + hypotension + clear lung fields + JVP elevation → presumptive RV extension; obtain V4R immediately; Routed from cardio.stemi.inferior.v1 after V4R+ confirmed.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Right-ventricular extension STEMI (proximal RCA)** (cardio.stemi.right-ventricular.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **RV-extension STEMI hemodynamic phenotype — adds to parent cardio.stemi.core.v1 reperfusion regimen; dominated by preload-dependence**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; same as parent
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo default DAPT (p2y12_inhibitor, first line) — PLATO PMID 19717846; same as parent
3. normal saline 500-1000 mL bolus, repeat to total 1-2L IV titrated to BP/JVP/lung exam (crystalloid, first line) — Preload-dependent state — volume loading is first-line for hypotension; Kinch & Ryan PMID 8208270; AHA 2025 Class I
4. dobutamine 2-10 mcg/kg/min IV IV continuous infusion (inotrope_beta1_selective, rescue) — Inotropic support for RV failure unresponsive to volume; AHA 2025 Class IIa
5. nitroglycerin CONTRAINDICATED — Class III AHA 2025 IV/SL avoid (nitrate, contraindication substitute) — 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)
6. furosemide CONTRAINDICATED in acute RV-extension IV avoid (loop_diuretic, contraindication substitute) — 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)
7. morphine AVOID — venodilator + sympathetic blunting IV avoid (opioid_pain, contraindication substitute) — 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)

Setting playbook (outpatient) — Long-term cardiology surveillance: secondary prevention bundle maintenance; RV recovery confirmation; cardiac rehab completion
8. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + BB PO as scheduled — post-RV-MI (AHA 2025)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase
- Document RV-MI history for future provider awareness

AVOID / contraindication checks:
- Nitrates_class_III_in_rv_extension (AHA 2025)
- Diuretics_class_III_in_acute_rv_extension (AHA 2025)
- Morphine_avoid_in_rv_extension (AHA 2025)
- Beta_blocker_defer_until_rv_failure_resolves (AHA 2025)

Monitoring

Regimen monitoring:
- arterial line if hypotension or vasopressor dependence
- echo at 24-72h for rv recovery assessment
- serial jvp and lung exam for volume balance
- central access if inotrope or vasopressor required

Setting (outpatient) monitoring:
- Quarterly + annual EF + RV function + lipid

Follow-up plan: Cardiology follow-up; echo at 30 d for RV recovery confirmation; cardiac rehab (caution with diuretic prescription if persistent RV dysfunction)
- Close-out criterion: cardiac rehab booked + RV function reassessed

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term cardiology surveillance: secondary prevention bundle maintenance; RV recovery confirmation; cardiac rehab completion

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if RV/LV dysfunction persists

Escalation triggers (move to higher acuity):
- EF or RV function declining → advanced HF eval
- Recurrent angina → cath re-eval

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] V4R+ inferior STEMI + SBP <90 not responsive to NS 1-2L bolus
- [LIFE_THREATENING] Patient received nitrate, diuretic, or morphine prior to V4R recognition; profound hypotension developed
- [SEVERE] V4R+ + 2°-3° AV block (often coexists in proximal RCA lesions affecting AV-node supply)

Citations

- 2025 ACC/AHA ACS Guideline + ESC 2023 ACS + Kinch & Ryan NEJM 1994 [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)
- Cited evidence (PMID 31475795) [PMID:31475795](https://pubmed.ncbi.nlm.nih.gov/31475795/)
- Cited evidence (PMID 8208270) [PMID:8208270](https://pubmed.ncbi.nlm.nih.gov/8208270/)

Last reconciled with current guidelines: 2026-05-14.
References