Right Ventricular Dysfunction in Acute Myocardial Infarction: A Contemporary Reappraisal of Pathophysiological Mechanisms, Prognostic Implications, and Evolving Therapeutic Paradigms

Abstract

Right ventricular dysfunction (RVD) represents a critical and often underappreciated determinant of clinical outcomes in the setting of acute myocardial infarction (AMI). While historical focus has predominantly centered on the left ventricle, emerging evidence underscores the pivotal role of the right ventricle (RV) as a key prognosticator, particularly in cases of inferior wall myocardial infarction complicated by proximal right coronary artery occlusion. The unique pathophysiological sequelae of RV infarction initiate a vicious cycle of impaired contractility, reduced left ventricular preload, and consequent systemic hypotension, further exacerbating coronary perfusion in a feedback loop of ischemia and dysfunction. This complex pathophysiology, involving intricate ventricular interdependence and the RV's sensitivity to afterload, necessitates a sophisticated diagnostic approach. Contemporary management, heavily reliant on early revascularization through percutaneous coronary intervention, aims to disrupt this cycle; however, the optimal supportive pharmacological and mechanical circulatory support strategy remains a subject of intense investigation, as conventional therapies for left heart failure may be deleterious in the context of predominant RV failure. This article synthesizes the most current clinical evidence to provide a comprehensive review of the pathophysiology, diagnostic modalities, risk stratification, and evidence-based management strategies for RVD in AMI, highlighting its independent prognostic value and the urgent need for RV-specific treatment protocols to improve patient survival and functional recovery.