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Answer 2
  1. IV fluid administration. This patient has an inferior MI involving the right ventricle. Fluid administration to increase preload and cardiac output is the critical initial step to stabilize this patient for percutaneous coronary intervention. Patients who undergo immediate reperfusion of RV branches have decreased 30-day mortality and improved RV function.2 Right heart catheterization may also be important to prevent volume overload. In general, a central venous pressure of 14 to 16 mm Hg is appropriate. Although IV nitroglycerin is commonly used in patients with acute MI, in this patient it would be contraindicated because it would decrease preload and cause hypotension. Patients with RV infarct frequently require IV inotropic agents (eg, dopamine, dobutamine); however, these agents should be used when volume loading fails. In addition, dobutamine has been shown to be superior to other agents in improving cardiac index and RV ejection fraction.3 An IABP may be useful, but it is not part of the initial management.

     Bowers TR, O’Neill WW, Grines C, et al. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998;338:933-40.

    3. Dell’Italia LJ, Starling MR, Blumhardt R, et al. Comparative effects of volume loading, dobutamine, and nitroprusside in patients with predominant right ventricular infarction. Circulation 1985;72:1327-35.

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