Correspondence

Right Ventricular Infarction

N Engl J Med 1993; 329:1043September 30, 1993

Article

To the Editor:

Zehender et al. (April 18 issue)1 reported important observations about the prognostic value of electrocardiographic evidence of right ventricular infarction in patients with an acute inferior myocardial infarction. The authors, however, provided no data regarding the degree of regional and global dysfunction in the right ventricle or the magnitude of concomitant left ventricular dysfunction, as assessed by objective criteria, such as regional wall motion and ejection fraction. My colleagues and I have previously shown that right ventricular dysfunction in acute myocardial infarction is not of independent prognostic importance, except in patients with severe concomitant left ventricular dysfunction2. Since clinical criteria alone are not sufficiently accurate to assess the severity of ventricular dysfunction in acute myocardial infarction, one cannot rule out the possibility that some of the patients with electrocardiographic signs of right ventricular dysfunction may have had concomitant severe left ventricular dysfunction as well. This might account for the results reported by Zehender et al.

Prediman K. Shah, M.D.
Cedars-Sinai Medical Center, Los Angeles, CA 90048

2 References

1. 1

   Zehender M, Kasper W, Kauder E, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 1993;328:981-988
   Full Text | Web of Science | Medline

2. 2

   Shah PK, Maddahi J, Staniloff HM, et al. Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction. Am J Cardiol 1986;58:387-393
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Zehender replies:

To the Editor: Shah et al.1 studied left and right ventricular ejection fractions during the acute phase of myocardial infarction. In patients in Killip classes I and II, a low right ventricular ejection fraction (0.38 or less) was an independent risk factor for death within one year, but only in the presence of concomitant left ventricular dysfunction. These interesting observations, however, were made in a selected group of patients: more than half had an anterior-wall infarction. Thus, the results are not applicable to our study, which included only patients with inferior myocardial infarction. Furthermore, in the study by Shah et al., it was not known whether an acute right ventricular infarction was present. During follow-up only nine patients with inferior myocardial infarction died. This, in my opinion, precludes the drawing of definite conclusions -- a point mentioned by the authors. Nevertheless, I agree with Shah that there is good evidence that the presence of depressed right and left ventricular ejection fractions in the setting of acute myocardial infarction is associated with a worse outcome.

Manfred Zehender, M.D.
Medizinische Universitatsklinik Freiburg, 79106 Freiburg, Germany

1 References

1. 1

   Shah PK, Maddahi J, Staniloff HM, et al. Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction. Am J Cardiol 1986;58:387-393
   CrossRef | Web of Science | Medline