Management of Crashing Patients with Pulmonary Hypertension

Right heart failure: A narrative review for emergency clinicians

INTRODUCTION

Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary arterial pressure, or volume overload. Emergency department (ED) patients with an acute RHF exacerbation can be diagnostically and therapeutically challenging to manage.

OBJECTIVE

This narrative review describes the pathophysiology of right ventricular dysfunction and pulmonary hypertension, the methods to diagnose RHF in the ED, and management strategies.

DISCUSSION

Right ventricular contraction normally occurs against a low pressure, highly compliant pulmonary vascular system. This physiology makes the right ventricle susceptible to acute changes in afterload, which can lead to RHF. Patients with acute RHF may present with an acute illness and have underlying chronic pulmonary hypertension due to left ventricular failure, pulmonary arterial hypertension, chronic lung conditions, thromboemboli, or idiopathic conditions. Patients can present with a variety of symptoms resulting from systemic edema and hemodynamic compromise. Evaluation with electrocardiogram, laboratory analysis, and imaging is necessary to evaluate cardiac function and end organ injury. Management focuses on treating the underlying condition, optimizing oxygenation and ventilation, treating arrhythmias, and understanding the patient's hemodynamics with bedside ultrasound. As RHF patients are preload dependent they may require fluid resuscitation or diuresis. Hypotension should be rapidly addressed with vasopressors. Cardiac contractility can be augmented with inotropes. Efforts should be made to support oxygenation while trying to avoid intubation if possible.

CONCLUSIONS

Emergency clinician understanding of this condition is important to diagnose and treat this life-threatening cardiopulmonary disorder.