Cardiology: right ventricular infarction: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Cardiology: right ventricular infarction

Sample item

A 60-year-old man has an inferior ST-elevation myocardial infarction. He is hypotensive at 80/50 mmHg with a raised jugular venous pressure, clear lung fields and ST elevation in lead V4R. What is the most appropriate initial management of his hypotension?

AA cautious intravenous normal saline bolus, avoiding nitrates and diureticsBIntravenous metoprolol to reduce myocardial oxygen demandCSublingual glyceryl trinitrate to relieve ischaemic painDIntravenous furosemide to lower the raised venous pressure

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

A. A cautious intravenous normal saline bolus, avoiding nitrates and diuretics

Right ventricular infarction (usually from proximal right coronary occlusion) makes cardiac output dependent on right ventricular preload. The triad of hypotension, raised JVP and clear lungs, with ST elevation in V4R, is typical. Volume loading restores preload, whereas nitrates, diuretics and morphine reduce preload and cause profound hypotension. Reperfusion remains the definitive therapy.

Option by option

A. A cautious intravenous normal saline bolus, avoiding nitrates and diuretics (correct)
Fluid expands preload to the stunned right ventricle, raising output and blood pressure.
B. Intravenous metoprolol to reduce myocardial oxygen demand
A beta-blocker reduces contractility and heart rate, and is dangerous in a hypotensive patient.
C. Sublingual glyceryl trinitrate to relieve ischaemic pain
Nitrates are venodilators and can cause severe hypotension in right ventricular infarction.
D. Intravenous furosemide to lower the raised venous pressure
A diuretic lowers preload further and would worsen hypotension in a preload-dependent ventricle.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is A, A cautious intravenous normal saline bolus, avoiding nitrates and diuretics. Right ventricular infarction (usually from proximal right coronary occlusion) makes cardiac output dependent on right ventricular preload.

Why is "Intravenous metoprolol to reduce myocardial oxygen demand" not the answer?

A beta-blocker reduces contractility and heart rate, and is dangerous in a hypotensive patient.

Why is "Sublingual glyceryl trinitrate to relieve ischaemic pain" not the answer?

Nitrates are venodilators and can cause severe hypotension in right ventricular infarction.

Why is "Intravenous furosemide to lower the raised venous pressure" not the answer?

A diuretic lowers preload further and would worsen hypotension in a preload-dependent ventricle.

What concept does this question test?

It tests Cardiology: right ventricular infarction in General Medicine. The triad of hypotension, raised JVP and clear lungs, with ST elevation in V4R, is typical. Volume loading restores preload, whereas nitrates, diuretics and morphine reduce preload and cause profound hypotension. Reperfusion remains the definitive therapy.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Cardiology: right ventricular infarction?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.