The Preload Trap in Emergency Medicine
Why standard chest pain protocols can cause cardiovascular collapse in an Inferior Wall MI.
​If a patient arrives clutching their chest profoundly diaphoretic with a BP of 92/60 and a heart rate of 48 your instinct might be the standard MONA protocol (Morphine, Oxygen, Nitro, Aspirin).
​If you give Nitroglycerin here their blood pressure will likely bottom out. Here is the clinical physiology behind why this happens.
​When a 12-lead ECG shows ST-elevation in leads II, III, and aVF, you are looking at an acute Inferior Wall STEMI.
The inferior wall of the heart is primarily supplied by the Right Coronary Artery (RCA) which also supplies the Right Ventricle (RV).
​If the RV is infarcted it loses its ability to pump effectively. The heart becomes completely dependent on preload (venous blood return) to maintain any forward cardiac output.
​Nitroglycerin is a potent venous vasodilator.
It pools blood in the veins drastically dropping preload. In a patient with a Right Ventricular infarct dropping their preload takes away the only mechanical advantage keeping their blood pressure afloat.
​Instead of vasodilators these patients often need IV fluid boluses (like 500cc of Normal Saline) to maximize preload alongside Aspirin a P2Y12 inhibitor Heparin and immediate Cath Lab activation. Always grab a right-sided ECG (leads V3R-V6R) to confirm RV involvement before giving standard meds in an inferior MI.
​How does your specific ER protocol handle the transition from a standard 12-lead to a right-sided ECG during a high-pressure code STEMI?
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