Accuracy of Clinical Symptoms, Electrocardiographic and Echocardiographic Parameters for Diagnosis of Significant Proximal Right Coronary Artery Lesion in Acute Inferior Wall Myocardial Infarction

Ahmed Hassouna Shetaya, Khaled Elkhashab, Gomaa Abdel Razek



Aim: Tissue Doppler (TDI) systolic annular velocity (S') and myocardial performance index may be useful  predictors of proximal right coronary artery (RCA) stenosis as a culprit lesion in Inferior wall myocardial infaection in association with clinical symptoms and ECG changes. 

Methods: In a prospective study, patients with first episode of acute IWMI underwent early conventional and tissue Doppler echocardiographic  assessment (within 24 h) of symptom onset and RV indices ; Tricuspid annular systolic plane excursion(TAPSE), myocardial performance index (MPI) and tissue Doppler velocities from RV free wall were measured. Patients  underwent coronary angiogram within one month, our Patients  divided into two groups(A,B) according to angiographic findings based on the presence or absence of a significant proximal RCA stenosis.

 Results:  There were 35 patients with first episode of IWMI, group A includes (n 14 patient) and group B includes  (n 21patient), There was significant difference between groups in TAPSE (1.28cm  vs 1.98 p < 0.001) ,MPI-TDI (0.69±0.12  vs 0.38±0.05 p < 0.001), and in  S'velocity from RV free wall ( 0.09m/s±0.02  vs  0.12m/s ±0.02  p < 0.001). It was found that S'<10cm/s is apredictor of proximal RCA lesion with sensitivity of 92.86% and specificity of 85.71%ppv 81.25, npv 94.74 , MPI-TDI>0.55 with a sensitivity of  92.86 % and specificity of 100% ,100% PPV and 95.45% NPv, and TAPSE<16mm (sensitivity93%, specificity100%).

 Conclusion; RV indices (S' velocity, MPI-TDI and TAPSE ) are useful in predicting proximal RCA as infarct related artery in IWMI.


Right ventricular function, Right coronary artery stenosis , Right ventricular infarction, Inferior wall myocardial infarction.

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(1) O’Rourke RA, Dell’Italia LJ. Diagnosis and management of right ventricular myocardial infarction. Curr Probl Cardiol. 2004;29:6e47.

(2) Claudia D, David L, et al. (2013): Right ventricular infarction. Medscape J. 71 (6): 307–12

(3) Shiraki H, Yoshikawa T, Anzai T, et al. (1998): "Association between pre-infarction angina and a lower risk of RV infarction".Nengl J Med.

(4) Mavric Z, Zaputovic L, Matana A, Kucic J, Roje J, Marinovic D, et al. Prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and without right ventricular involvement. Am Heart J. 1990 Apr. 119 (4): 823-8. Doi: 10.1016/S0002-8703(05)80318-7

(5) Erhardt LR, Sjogren A et al. (1976): "single right sided precordial lead in the diagnosis of right ventricular involvement in inferior myocardial infarction".Am heart J.

(6) Braat SH, Brugada p, et al. (1983): "value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction". Br Heart J. DOI: 10.1016/S0002-8703(76)80141-X

(7) Sorin G, André La, et al. (2010): "The echocardiographic assessment of the right ventricle: what to do in 2010 ". Oxford J. DOI:10.1136/hrt.49.4.368

(8) Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricle function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricle failure. Circulation. 2008; 117: 1717–31.

(9) Jurcut R, Giusca S, La Gerche A, Vasile S, Ginghina C, Voigt JU. The echocardiographic assessment of the right ventricle: what to do in 2010? Eur J Echocardiogr. 2010; 11: 81–96.

(10) Rudski LG, Lai WW, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, et al. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from American Society of Echocardiography . J Am Soc Echocardiogr. 2010; 23: 685–713.

(11) Sanders AO. Coronary thrombosis with complete heart block and relative ventricular tachycardia: a case report. Am Heart J.1930;6:820e823.

(12) Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictorof prognosis afteracute inferior myocardial failure, and stroke following myocardial infarction (from the VALIANT ECHO Study).Am J Cardiol.2008; 101: 607 e 612.

(13) Jacobs AK, Leopold JA, Bates E, et al. Cardiogenic shock caused by right ventricular infarction: a report from the SHOCK registry. J Am Coll Cardiol. 2003;41:1273e1279.

(14) Mittal SR, Garg S, Lalgarhia M. Jugular venous pressure and pulse wave form in the diagnosis of right ventricular infarction. Int J Cardiol 1996; 53 (3): 253–6.

(15) Witt N, Alam M, Svensson L, Samad BA. Tricuspid annular velocity assessed by Doppler tissue imaging as a marker of right ventricular involvement in the acute and late phase after a first ST elevation myocardial infarction. Echocardiography 2010; 27 (2): 139–45

(16) Goldstein JA. Pathophysiology and management of right heart ischemia. J Am CollCardiol 2002; 40 (5): 841–53

(17) Dell’Italia LJ, Starling MR, O’Rourke RA. Physical examination for exclusion of hemodynamically important right ventricular infarction. Ann Intern Med. 1983;99:608e611. Dell’Italia LJ. The right ventricle: anatomy, physiology, and clinical importance. Curr Prob Cardiol 1991;16(10):653–720. DOI: 10.1097/00001573-199907000-00009

(18) Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary. J Am CollCardiol 2004; 44 (3): 671–719.

(19) Zehender M, Kasper W, Kauder E, Schonthaler M, Geibel A, Olschewski M, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993;328(14):981–8.

(20) Saw J, Davies C, Fung A, et al. Value of ST elevation in lead III greater than lead II in inferior wall acute myocardial infarction for predicting in-hospital mortality and diagnosing right ventricular infarction. Am J Cardiol. 2001;87:448e450. DOI: 10.1056/NEJM199304083281401

(21) Alam M, Wardell J, Andersson E, Samad BA, Nordlander R. Right ventricular function in patients with first inferior myocardial infarction: assessment by tricuspid annular motion and tricuspid annular velocity. Am Heart J 2000;139(4):710–5. DOI: 10.1016/S0002-9149(00)01401-6

(22) Samad BA, Alam M, Jensen-Urstad K. Prognostic impact of right ventricular involvement as assessed by tricuspid annular motion in patients with acute myocardial infarction. Am J Cardiol. 2002;90:778e781. DOI: 10.1016/S0002-8703(00)90053-X

(23) Kaul S, Tei C, Hopkins JM, Shah PM. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J. 1984;107:526e531. DOI: 10.1016/S0002-9149(02)02612-7

(24) Coghlan JG, Davar J. How should we assess right ventricular function in 2008? Eur Heart J Suppl. 2007;9:H22eH28. DOI: 10.1016/0002-8703(84)90095-4

(25) Anand Chockalingam AB, Gnanavelu G, Alagesan R, Subramaniam T. Myocardial performance index in evaluation of acute right ventricular myocardial infarction. Echocardiography. 2004;216:487e494. DOI: 10.1093/eurheartj/sum027

(26) Kakouros N, Kakouros S, Lekakis J, Rizos I, Cokkinos D. Tissue Doppler imaging of the tricuspid annulus and myocardial perfor- mance index in the evaluation of right ventricular . Echocardiography 2011; 28 (3): 311–9. DOI: 10.1111/j.0742-2822.2004.03139.x

(27) Rambaldi R, Poldermans D, Fioretti PM, ten Cate FJ, Vletter WB, Bax JJ, et al. Usefulness of pulse-wave Doppler tissue sampling and dobutamine stress echocardiography for the diagnosis of rightcoronary artery narrowing.Am J Cardiol1998; 81 (12): 1411–5.

(28) Ozdemir K, Altunkeser BB, Icli A, Ozdil H, Gok H. New parameters in identification of right ventricular myocardial infarction and proximal right coronary artery lesion. Chest 2003;124(1):219–26.

(29) Meluzin J, Spinarova L, Bakala J, Toman J, Krejci J, Hude P, et al. Pulsed Doppler tissue imaging of the velocity of tricuspidannular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function. Eur Heart J 2001;22(4):340–8.

(30) Karnati PK, El-Hajjar M, Torosoff M, et al. Myocardial performance index correlates with right ventricular ejection fraction measured by nuclear ventriculography. Echocardiography. 2008; 25: 381 e 385.

(31) Fan Y, Shen JX, Yang SS, Xiu CH, Wang LF, Xue FH, et al. Evaluation of right ventricular function by tissue Doppler echocardiography and Tei index in right ventricular myocardial infarction. Zhonghua Nei Ke Za Zhi 2005; 44 (3): 180–3. DOI: 10.1111/j.1540-8175.2007.00601.x

(32) Gopalan N Rajesh, Deepak Raju, Deepak Nandan, et al. Cardiological Society of India . Echocardiographic assessment of right ventricular function in inferior wall myocardial infarction and angiographic correlation to proximal right coronary artery stenosis, i n d i a n heart journal 2 0 1 3; 65: 522-528 DOI: 10.1016/j.ihj.2013.08.021

(33) Shewan LG, Coats AJS, Henein M. Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015;2:2 DOI: 10.17987/icfj.v2i1.4


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