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cardio.acute-hf.right-sided.v1

Acute HF — RV-predominant decompensated HF

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.acute-hf.core.v1 — RV-predominant ADHF spectrum (RV-MI extension, severe PH crisis, post-pulmonary embolectomy, post-CT-surgery RV failure, decompensated cor pulmonale). Specializes preload-dependent treatment (careful 250-500 mL crystalloid bolus per Goldstein NEJM 1990), pulmonary vasodilator (iNO 20-40 ppm OR inhaled epoprostenol 50 ng/kg/min), inotrope (dobutamine), and AVOIDS isolated LV-MCS (Impella CP worsens RV by reducing LV filling) — Impella RP or VA-ECMO preferred per DanGer Shock 2024 (PMID 38587234) context. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (RV-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • imaging
    Echo with severe RV dilation + dysfunction (TAPSE <14, RVFAC <25%) + low PCWP → RV-predominant ADHF
    echo_severe_rv_dysfunction
  • history
    Inferior STEMI + V4R ST elevation + hypotension + clear lungs → RV infarction (Goldstein NEJM 1990)
    rv_mi_extension_with_hypotension
  • symptom
    Known PAH/PH + acute decompensation (syncope, pre-arrest, lactate rise) → PH crisis
    pulmonary_htn_crisis_with_decompensation
  • history
    Post-pulmonary embolectomy or post-CT-surgery with isolated RV failure
    post_pulmonary_embolectomy_or_post_ct_surgery_rv_failure

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Age affects MCS candidacy + transplant eligibility
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + clear lungs = RV-MI or PH crisis hallmark; SBP guides preload challenge vs inotrope
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia in RV failure may reflect right-to-left shunt across PFO; severe hypoxemia drives pulmonary vasoconstriction and worsens RV
  • echo_rv_focusedrequired
    imaging • used at INITIAL_WORKUP
    TAPSE, RVFAC, RV/LV ratio, septal flattening, RV s-prime; echo is cornerstone of RV phenotyping
  • lactaterequired
    lab • used at RED_FLAGS
    Lactate ≥2 = perfusion failure; tracking response to inotrope/vasodilator
  • creatininerequired
    lab • used at CONTEXT
    Renal congestion from elevated CVP; trend during therapy
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    RV strain marker; trend response to therapy
  • cvp_measurement
    imaging • used at INITIAL_WORKUP
    Elevated CVP + low PCWP discriminates RV failure from LV failure; PA catheter often needed
  • precipitant_pe_pah_rvmi_postsurgical
    history • used at BRANCHING_WORKUP
    Identify trigger (PE, PAH, RV-MI, postsurgical) — drives etiology-specific therapy

12-phase flow (10)

  1. 1FRAME
    RV-predominant ADHF = low CO + high CVP + low PCWP + low PA; preload-dependent; over-diuresis harmful; isolated LV-MCS contraindicated
    inputs: echo_rv_focused
    advance: RV phenotype confirmed
  2. 2ENTRY
    Recognize RV phenotype: clear lungs + hypotension + JVD + cool extremities ± hepatomegaly; bedside echo for RV size/function
    inputs: sbp, echo_rv_focused
    advance: RV phenotype recognized
  3. 3CONTEXT
    Etiology screen: STEMI ECG (V4R), PE risk factors, known PAH, recent CT surgery; med list (PDE5i, prostacyclin doses); home RV regimen
    inputs: age, creatinine
    advance: context complete
  4. 4RED_FLAGS
    Cardiogenic shock with RV phenotype (lactate ≥2, MAP <65); arrhythmia (AF/flutter — RV-dependent); refractory hypoxemia
    inputs: sbp, spo2, lactate
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    ECG (V4R if inferior STEMI; S1Q3T3 + RBBB for PE), echo (RV size/function, septal flattening, PASP, RAP), CTPA if PE suspected, NT-proBNP, lactate, BMP, troponin, lung US (clear in pure RV failure)
    inputs: nt_probnp, lactate
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    PA catheter for hemodynamic phenotyping (high CVP + low PCWP confirms RV; high PVR confirms PH); cardiac MRI if myocarditis or infiltrative; right heart cath if vasoreactivity testing needed
    inputs: cvp_measurement
    advance: hemodynamic phenotype clarified
  7. 7TREATMENT
    PRELOAD: careful 250-500 mL crystalloid bolus if euvolemic/hypovolemic; AVOID over-resuscitation (worsens RV dilation). PULMONARY VASODILATOR: inhaled NO 20-40 ppm OR inhaled epoprostenol 50 ng/kg/min. INOTROPE: dobutamine 2.5-10 µg/kg/min for RV inotropic support; milrinone alternative (also pulmonary vasodilator) if not hypotensive. VASOPRESSOR: norepinephrine to MAP ≥65 (preserves coronary perfusion to RV). DIURETIC: cautious — only if clearly volume-overloaded. AVOID: isolated LV-MCS (Impella CP worsens RV); consider Impella RP or VA-ECMO for biventricular support
    inputs: sbp, lactate
    actions: protocol.cardiogenic_shock
    advance: preload + vasodilator + inotrope strategy active
  8. 8DISPOSITION
    CICU mandatory; advanced HF transfer if MCS need or refractory PH crisis
    advance: unit + transfer plan documented
  9. 9MONITORING
    Continuous arterial line, CVP/PA catheter if available, hourly UOP, daily echo until stable, q6h lactate + BMP, telemetry
    inputs: lactate, creatinine
    actions: panel.cardiac
    advance: monitoring active
  10. 10FOLLOWUP
    PAH-specific therapy escalation if PH crisis; cardiac rehab; advanced HF + transplant/LVAD eval if recurrent RV decompensation
    advance: PAH clinic + advanced HF eval booked