A 64-year-old woman presents 2 hours after onset of crushing chest pain. ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. She develops hypotension (BP 80/50), raised JVP, clear lung fields, and no S3. The right-sided ECG shows ST elevation in V4R. What is the most appropriate immediate next step?
- A IV normal saline fluid challenge 200–300 mL bolus ✓
- B IV furosemide 40 mg to reduce preload
- C IV nitrates for afterload reduction
- D Dobutamine infusion as first-line vasopressor
Correct answer: A. IV normal saline fluid challenge 200–300 mL bolus
Explanation
This presentation is right ventricular infarction complicating inferior STEMI (ST elevation in V4R is diagnostic). RV infarction causes a preload-dependent state; hypotension is managed with IV fluid resuscitation to maintain RV filling pressure. Nitrates and diuretics are absolutely contraindicated as they further reduce preload and can precipitate cardiovascular collapse.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.