A 65-year-old man presents with STEMI in leads II, III, and aVF. His blood pressure drops to 80/50 mmHg despite 1 L IV fluid. ECG shows ST elevation in V4R. The MOST likely diagnosis and immediate management is:
- A Left ventricular failure; start dobutamine infusion
- B Right ventricular infarction; aggressive IV fluid resuscitation and avoid nitrates ✓
- C Papillary muscle rupture; emergency surgery
- D Cardiac tamponade; pericardiocentesis
Correct answer: B. Right ventricular infarction; aggressive IV fluid resuscitation and avoid nitrates
Explanation
ST elevation in the right-sided lead V4R in the setting of inferior STEMI indicates right ventricular infarction (Bezold-Jarisch reflex causes bradycardia/hypotension). Management relies on IV fluid loading to maintain RV preload, and nitrates/diuretics are strictly contraindicated as they cause fatal preload reduction. Dobutamine is used for refractory RV failure after fluid optimisation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.