Emergency Department Management of Patients With Right Heart Failure

Table of Contents

 

About This Issue

Right heart failure (RHF) can be an acute or a chronic condition that is diagnosed as being caused by or presenting with many pulmonary, cardiovascular, and chronic conditions. Recognition of RHF is essential in offering treatment for underlying etiology, treat the RHF, and avoid decompensation. In this issue, you will learn:

How to recognize when RHF is caused by a medical condition (pulmonary embolism, sepsis, heart failure) and when it has no clear etiology.

The common ED diagnoses that are associated with RHF, and how they can point to RHF as the underlying cause.

The 5 classifications of pulmonary hypertension and their associated comorbidities.

The congenital cardiac conditions associated with RHF and their mechanisms of causation.

Screening for extrapulmonary manifestations of RHF: hepatic, renal, and cardiovascular.

How to use transthoracic echocardiography and TAPSE values to diagnose RHF.

The cautions on managing ventilation in patients with impaired right ventricle function.

Choosing treatment for RHF: revascularization, optimization of preload, respiratory support, vasopressors and inotropes, and mechanical circulatory support.

How to determine a patient’s disposition, based on the underlying cause of the RHF.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Selected Abbreviations
6. Critical Appraisal of the Literature
7. Etiology and Pathophysiology
8. Differential Diagnosis
   1. Causes of Acute Right Heart Failure
      1. Acute Pulmonary Embolism
      2. Sepsis
      3. Right Ventricular Myocardial Infarction
      4. Positive Pressure Ventilation and Acute Respiratory Distress Syndrome
      5. Acute Respiratory Distress Syndrome
      6. COVID-19
   2. Causes of Chronic Right Heart Failure
      1. Chronic Thromboembolic Pulmonary Hypertension
      2. Heart Failure
      3. Congenital Heart Disease
      4. Left Ventricular Assist Devices
      5. Lung Diseases and Group 3 Pulmonary Hypertension
      6. Pulmonary Arterial Hypertension
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
11. Diagnostic Studies
    1. Biomarkers
    2. Electrocardiogram
    3. Transthoracic Echocardiography
    4. Computed Tomography
    5. Magnetic Resonance Imaging
    6. Summary of Diagnosis of Right Heart Failure
12. Treatment
    1. Revascularization
    2. Optimization of Preload
    3. Respiratory Support
    4. Vasopressors and Inotropes
    5. Mechanical Circulatory Support
13. Special Populations
    1. Patients on Pulmonary Vasodilators
14. Controversies and Cutting Edge
    1. Speckle-Tracking Echocardiography
    2. Advanced Therapies
15. Disposition
    1. Patients With Pulmonary Embolism
    2. Patients With Acute Decompensated Heart Failure
    3. Patients With Congenital Heart Disease
    4. Patients Requiring Higher Levels of Care
16. Summary
17. Time- and Cost-Effective Strategies
18. 5 Things That Will Change Your Practice
19. Risk Management Pitfalls for Emergency Department Patients with Right Heart Failure
20. Case Conclusions
21. Clinical Pathways
    1. Clinical Pathway for Clinical Suspicion for Right Heart Failure in the Emergency Department
    2. Clinical Pathway for Etiology-Specific Care of Right Heart Failure in the Emergency Department
22. Tables and Figures
23. References

Abstract

Right heart failure (RHF) can result from many cardiac, pulmonary, and systemic pathologies. Common causes of RHF include pulmonary embolism, left heart failure, congenital heart disease, chronic lung disease, acute myocardial infarction, infiltrative disease, infectious disease, and valvular abnormalities. Acute and chronic RHF confer a high risk for morbidity and mortality in the acute care setting, and interventions commonly used in emergency care can prompt acute decompensation if the RHF is not recognized. The severity of presentation may range from compensated clinically silent cardiovascular dysfunction to venous congestion, multiorgan failure, and circulatory collapse. This review describes the pathophysiology of right heart failure and offers an evidence-based approach to the diagnosis, management, and disposition of both acute and chronic RHF.

Case Presentations

A 40-year-old woman presents with dyspnea, tachycardia, and hemoptysis…

• Her vital signs are: temperature, 36.9°C; heart rate, 125 beats/min; blood pressure, 120/65 mm Hg; respiratory rate, 24 breaths/min; and oxygen saturation, 94%.
• She takes estrogen-containing medications, and reports that she recently had a cross-continental airplane flight.
• As you place initial orders, you consider whether transthoracic echocardiography would aid in her evaluation and management…

A 64-year-old man with a history of heart failure reports severe fatigue and dyspnea…

• His vital signs are: temperature, 36.5°C; heart rate, 115 beats/min; blood pressure, 150/90 mm Hg; and respiratory rate, 26 breaths/min. In the ED, his resting oxygen saturation is 93%.
• He states that he is compliant with his diuretic therapy, but he has developed worsened lower extremity edema.
• What aspects of cardiac function most acutely correspond to his symptoms and risk for adverse events?

A 52-year-old woman with COVID-19 and severe respiratory distress develops hemodynamic instability immediately after you intubate her…

• Her vital signs are: temperature, 37.5°C; heart rate, 130 beats/min; blood pressure, 75/42 mm Hg; and respiratory rate, 22 breaths/min.
• What are the likely causes of her shock, and what should you do to stabilize her?

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Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Konstam MA, Kiernan MS, Bernstein D, et al. Evaluation and management of right-sided heart failure: a scientific statement from the American Heart Association. Circulation. 2018;137(20):e578-e622. (Guideline) DOI: 10.1161/CIR.0000000000000560

* Harjola VP, Mebazaa A, Celutkiene J, et al. Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology. Eur J Heart Fail. 2016;18(3):226-241. (Guideline) DOI: 10.1002/ejhf.478

21. * Gorter TM, Hoendermis ES, van Veldhuisen DJ, et al. Right ventricular dysfunction in heart failure with preserved ejection fraction: a systematic review and meta-analysis. Eur J Heart Fail. 2016;18(12):1472-1487. (Systematic review, meta-analysis; 4835 patients) DOI: 10.1002/ejhf.630

22. * Harrison NE, Ehrman R, Favot M, et al. Right ventricular dysfunction in acute heart failure from emergency department to discharge: predictors and clinical implications. Am J Emerg Med. 2022;52:25-33. (Prospective study; 84 patients) DOI: 10.1016/j.ajem.2021.11.024

24. * Judge P, Meckler G. Congenital heart disease in pediatric patients: recognizing the undiagnosed and managing complications in the emergency department. Pediatr Emerg Med Pract. 2016;13(5):1-28. (Review)

37. * Huang SJ, Nalos M, Smith L, et al. The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research. Intensive Care Med. 2018;44(6):868-883. (Systematic review, meta-analysis; 81 studies) DOI: 10.1007/s00134-018-5211-z

38. * Harrison NE, Favot MJ, Gowland L, et al. Point-of-care echocardiography of the right heart improves acute heart failure risk stratification for low-risk patients: the Reed-AHF prospective study. Acad Emerg Med. 2022;29(11):1306-1319. (Prospective study; 120 patients) DOI: 10.1111/acem.14589

53. * Lim P, Delmas C, Sanchez O, et al. Diuretic vs. placebo in intermediate-risk acute pulmonary embolism: a randomized clinical trial. Eur Heart J Acute Cardiovasc Care. 2022;11(1):2-9. (Randomized controlled trial; 276 patients) DOI: 10.1093/ehjacc/zuab082

83. * Mekontso Dessap A, Boissier F, Charron C, et al. Acute cor pulmonale during protective ventilation for acute respiratory distress syndrome: prevalence, predictors, and clinical impact. Intensive Care Med. 2016;42(5):862-870. (Prospective study; 752 patients) DOI: 10.1007/s00134-015-4141-2

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Keywords: right heart failure, pulmonary hypertension; myocardial infarction, TAPSE, pulmonary embolism, sepsis, acute respiratory distress syndrome, ARDS, congenital, TTE, ECMO