Myocardial infarction: Kussmaul's sign diagnosed right ventricular infarction.

Clinical bottom line (level 1b)

  1. In patients with acute inferior myocardial infarction, the presence or absence of Kussmaul's sign ruled in or out right ventricular infarction .
  2. Small numbers may make this study unreliable
Dell'Italia et al: Annals of Internal Medicine 1983; 99 (5): 608-611
Expires March 2003

The study

Setting: university hospital, USA

53 patients (aged mean 55y (range 38y to 71y), 100% male) acute inferior myocardial infarctions (diagnosed by symptoms, ECG changes and enzyme changes)

Excluded if
  • severe COPD or PE
  • left-right shunts
  • renal failure
  • pericardial disease
  • biventricular heart failure



Independent unblinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • direct right atrial pressure measurement of >10 mmHg and a right atrial:pulmonary wedge pressure ratio >0.80
Diagnostic test: physical examination: JVP >8cm, Kussmaul's sign (JVP rising during quiet inspiration), pulmonary rales, murmurs of MR or TR, S3 or S4, systolic hypotension <100 mmHg

The evidence

pre-test probability of right ventricular infarction: 15%, (95% CI: 5.5% to 25%)

diagnostic test right ventricular infarction no haemodynamically significant infarction LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
Kussmaul's sign 8 0 infinity
(16 to infinity) 		100% 0.0
(0.0 to 0.27) 		0%
elevated JVP of 8 cm H2o or more 7 14 2.8
(1.7 to 4.7) 		33% 0.18
(0.03 to 1.2) 		3%
total 8 45

all physical signs had 'complete agreement' between two consultant cardiologists

Comments

  1. Small study with two experienced cardiologists; how do general clinicians compare?

Citation

  1. Dell'Italia LJ, Starling MR, O'Rourke RA: Physical examination for exclusion of hemodynamicaly important right ventricular infarction. Annals of Internal Medicine 1983; 99 (5): 608-611
Contributor: Bob Phillips and Clare Wotton, November 1999
Reviewer:

Clinical Question.
    Patient in patients with inferior ventricular infarction
    Intervention or Exposure physical examination
    Outcome rule out right ventricular infarction