This handout is for acute hf — rv-predominant decompensated hf. Your care team identified this based on: echo with severe rv dilation + dysfunction (tapse <14, rvfac <25%) + low pcwp → rv-predominant adhf.
Other reasons your team may use this plan: inferior stemi + v4r st elevation + hypotension + clear lungs → rv infarction (goldstein nejm 1990); known pah/ph + acute decompensation (syncope, pre-arrest, lactate rise) → ph crisis; post-pulmonary embolectomy or post-ct-surgery with isolated rv failure.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| normal saline 0.9% | 250-500 mL IV bolus over 15-30 min | IV | one bolus then reassess | Goldstein NEJM 1990 — RV is preload-dependent; small bolus often improves CO; STOP if CVP rises without CO improvement (over-distention) |
| dobutamine | 2.5 µg/kg/min IV titrate to 10 µg/kg/min | IV | continuous | Inotropic support for RV; less arrhythmogenic at low doses; preferred over isolated LV-MCS in RV failure |
| milrinone | 0.125-0.5 µg/kg/min IV (no bolus) | IV | continuous | Inodilator with pulmonary vasodilation — useful in RV failure with elevated PVR; renal adjustment; avoid if hypotensive (OPTIME-CHF) |
| norepinephrine | 0.05 µg/kg/min IV titrate to MAP ≥65 | IV | continuous | Maintains MAP for coronary perfusion to RV — coronary perfusion = MAP - CVP; SOAP-II PMID 20200382 |
| vasopressin | 0.03 U/min IV | IV | continuous; not titrated | V1-mediated vasoconstriction sparing pulmonary vasculature — preferred second pressor in RV failure with PH |
| inhaled nitric oxide | 20-40 ppm inhaled | INH | continuous | Selective pulmonary vasodilation reduces RV afterload; ESC 2021 HF Class IIb; wean slowly to avoid rebound PH |
| inhaled epoprostenol | 50 ng/kg/min nebulized | INH | continuous | Inhaled prostacyclin alternative to iNO; selective pulmonary vasodilation; lower cost than iNO |
| furosemide | CAUTIOUS — 20-40 mg IV ONLY if clearly volume-overloaded (rising CVP without CO improvement) | IV | as needed | Over-diuresis worsens RV preload; use only if clearly congested + monitor CVP + CO closely |
Plan: RV-predominant ADHF — preload-dependent, pulmonary vasodilator + dobutamine + AVOID isolated LV-MCS (ESC 2021 HF; Konstantinides 2019 PE)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
PAH-specific therapy escalation if PH crisis; cardiac rehab; advanced HF + transplant/LVAD eval if recurrent RV decompensation
Guideline: ESC 2021 HF + 2022 ACC/AHA HF + Konstantinides ESC 2019 PE