A Right Turn in Diagnosis: Highlighting the Importance of TAPSE in Isolated Right Ventricular Myocardial Infarction

TL;DR

This case report highlights how TAPSE can detect right ventricular dysfunction in a rare heart attack type that doesn't show typical ECG signs.

Contribution

The first known case report demonstrating the clinical utility of TAPSE in diagnosing isolated right ventricular myocardial infarction.

Findings

TAPSE was significantly reduced at 1 cm in a patient with isolated RVMI despite normal wall motion on ECG.

Right-sided ECG and POCUS were critical in identifying RV dysfunction when standard ECG findings were atypical.

The case emphasizes the importance of using TAPSE and cardiac POCUS in emergency settings for early RVMI detection.

Abstract

Isolated right ventricular myocardial infarction (RVMI) is a rare but significant clinical entity that can present with atypical findings on a standard electrocardiograph (ECG). We present the case of a 65-year-old man with a history of chronic smoking and alcohol use who presented to the emergency department with acute chest pain. An initial ECG showed ST-segment elevation in lead V1 and depression in leads I, aVL, and V2-V6, which did not meet ST-segment elevation myocardial infarction (STEMI) criteria. A right-sided ECG revealed ST-segment elevation in V3R-V6R, concerning for RVMI. Notably, cardiac point of care ultrasound (POCUS) demonstrated normal left ventricular (LV) function without LV or right ventricular (RV) regional wall motion abnormalities (RWMA). However, tricuspid annular plane systolic excursion (TAPSE) was significantly reduced at 1 cm, indicating RV dysfunction despite the absence of RWMA. This is the first known case report that highlights the importance of TAPSE in assessing RV function in isolated RVMI cases. Early recognition and management are crucial, especially in patients with typical presentations, as prompt treatment can prevent complications. This case underscores the need for emergency physicians to maintain a high index of suspicion for RVMI, particularly in atypical presentations, and to utilize cardiac POCUS as an essential tool for evaluation.

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