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cardio.acute-hf.right-sided.v1PRODUCTION
cardio.acute-hf.right-sided.v1

Acute HF — RV-predominant decompensated HF

cardiologyacuteadult
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10/12 authored

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Detailed

RV-predominant ADHF = low CO + high CVP + low PCWP + low PA; preload-dependent; over-diuresis harmful; isolated LV-MCS contraindicated

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RV phenotype confirmed

Patient inputs (9)

Age affects MCS candidacy + transplant eligibility

Renal congestion from elevated CVP; trend during therapy

TAPSE, RVFAC, RV/LV ratio, septal flattening, RV s-prime; echo is cornerstone of RV phenotyping

RV strain marker; trend response to therapy

Hypotension + clear lungs = RV-MI or PH crisis hallmark; SBP guides preload challenge vs inotrope

Hypoxemia in RV failure may reflect right-to-left shunt across PFO; severe hypoxemia drives pulmonary vasoconstriction and worsens RV

Lactate ≥2 = perfusion failure; tracking response to inotrope/vasodilator

Identify trigger (PE, PAH, RV-MI, postsurgical) — drives etiology-specific therapy

Elevated CVP + low PCWP discriminates RV failure from LV failure; PA catheter often needed

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (4)

4 need judgement
  • informationallife_threateningrv_predominant_shock_unresponsive_to_pressor_inotrope
    RV-predominant cardiogenic shock with persistent lactate ≥4, MAP <65 despite NE + vasopressin + dobutamine + iNO
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrv_failure_with_pulmonary_htn_crisis
    Known PAH + new syncope/pre-arrest/lactate rise + severely elevated PA pressure on echo
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrv_mi_extension_with_hypotension
    Inferior STEMI + V4R ST elevation + hypotension + clear lungs → RV-MI with shock
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_pe_with_rv_failure
    Hemodynamically unstable acute PE with RV failure on echo (RV/LV >1.0, septal flattening, low CO)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

RV-predominant ADHF — preload-dependent, pulmonary vasodilator + dobutamine + AVOID isolated LV-MCS (ESC 2021 HF; Konstantinides 2019 PE)
axis: rv_predominant_adhf_phenotype
Selected axis "RV-predominant ADHF — preload-dependent, pulmonary vasodilator + dobutamine + AVOID isolated LV-MCS (ESC 2021 HF; Konstantinides 2019 PE)" by default fallback (first axis)
  • normal saline 0.9%
    first line
    crystalloid
    250-500 mL IV bolus over 15-30 min • IV • one bolus then reassess
    triggers: rv_failure_with_low_cvp_or_euvolemic, preload_dependent_rv
    Goldstein NEJM 1990 — RV is preload-dependent; small bolus often improves CO; STOP if CVP rises without CO improvement (over-distention)
    rxcui 9863
  • dobutamine
    first line
    inotrope_beta1
    2.5 µg/kg/min IV titrate to 10 µg/kg/min • IV • continuous
    triggers: rv_failure_with_low_co
    Inotropic support for RV; less arrhythmogenic at low doses; preferred over isolated LV-MCS in RV failure
    rxcui 3616
  • milrinone
    second line
    pde3_inhibitor
    0.125-0.5 µg/kg/min IV (no bolus) • IV • continuous
    triggers: rv_failure_with_pulmonary_htn, bb_dependent_patient
    Inodilator with pulmonary vasodilation — useful in RV failure with elevated PVR; renal adjustment; avoid if hypotensive (OPTIME-CHF)
    rxcui 52769
  • norepinephrine
    first line
    vasopressor
    0.05 µg/kg/min IV titrate to MAP ≥65 • IV • continuous
    triggers: hypotension_with_rv_failure
    Maintains MAP for coronary perfusion to RV — coronary perfusion = MAP - CVP; SOAP-II PMID 20200382
    rxcui 7512
  • vasopressin
    rescue
    v1_agonist_vasopressor
    0.03 U/min IV • IV • continuous; not titrated
    triggers: ne_above_0.5_in_rv_failure
    V1-mediated vasoconstriction sparing pulmonary vasculature — preferred second pressor in RV failure with PH
    rxcui 11149
  • inhaled nitric oxide
    first line
    pulmonary_vasodilator_inhaled
    20-40 ppm inhaled • INH • continuous
    triggers: severe_pulmonary_htn_or_rv_failure
    Selective pulmonary vasodilation reduces RV afterload; ESC 2021 HF Class IIb; wean slowly to avoid rebound PH
    rxcui 7442
  • inhaled epoprostenol
    first line
    prostacyclin_inhaled
    50 ng/kg/min nebulized • INH • continuous
    triggers: severe_pulmonary_htn_no_no_available
    Inhaled prostacyclin alternative to iNO; selective pulmonary vasodilation; lower cost than iNO
    rxcui 8814
  • furosemide
    comorbidity specific
    loop_diuretic
    CAUTIOUS — 20-40 mg IV ONLY if clearly volume-overloaded (rising CVP without CO improvement) • IV • as needed
    triggers: rv_failure_with_overload
    Over-diuresis worsens RV preload; use only if clearly congested + monitor CVP + CO closely
    rxcui 4603

outpatient playbook — drug actions (2)

  1. 1. continue PAH therapy
    sildenafil + ambrisentan combination if dual therapy indicated • PO • as scheduled
    trigger: PAH confirmed
    AMBITION trial — combination therapy
  2. 2. continue 4-pillar GDMT if biventricular
    rxcui 593411
    ARNI + BB + MRA + SGLT2i at max tolerated • PO • as scheduled
    trigger: Biventricular HFrEF
    ACC/AHA 2022 HF

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Echo with severe RV dilation + dysfunction (TAPSE <14, RVFAC <25%) + low PCWP → RV-predominant ADHF; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute HF — RV-predominant decompensated HF** (cardio.acute-hf.right-sided.v1).
Scope: RV-predominant ADHF = low CO + high CVP + low PCWP + low PA; preload-dependent; over-diuresis harmful; isolated LV-MCS contraindicated

No severity triggers fired against current inputs.

Plan

Regimen axis: **RV-predominant ADHF — preload-dependent, pulmonary vasodilator + dobutamine + AVOID isolated LV-MCS (ESC 2021 HF; Konstantinides 2019 PE)**.
1. normal saline 0.9% 250-500 mL IV bolus over 15-30 min IV one bolus then reassess (crystalloid, first line) — Goldstein NEJM 1990 — RV is preload-dependent; small bolus often improves CO; STOP if CVP rises without CO improvement (over-distention)
2. dobutamine 2.5 µg/kg/min IV titrate to 10 µg/kg/min IV continuous (inotrope_beta1, first line) — Inotropic support for RV; less arrhythmogenic at low doses; preferred over isolated LV-MCS in RV failure
3. milrinone 0.125-0.5 µg/kg/min IV (no bolus) IV continuous (pde3_inhibitor, second line) — Inodilator with pulmonary vasodilation — useful in RV failure with elevated PVR; renal adjustment; avoid if hypotensive (OPTIME-CHF)
4. norepinephrine 0.05 µg/kg/min IV titrate to MAP ≥65 IV continuous (vasopressor, first line) — Maintains MAP for coronary perfusion to RV — coronary perfusion = MAP - CVP; SOAP-II PMID 20200382
5. vasopressin 0.03 U/min IV IV continuous; not titrated (v1_agonist_vasopressor, rescue) — V1-mediated vasoconstriction sparing pulmonary vasculature — preferred second pressor in RV failure with PH
6. inhaled nitric oxide 20-40 ppm inhaled INH continuous (pulmonary_vasodilator_inhaled, first line) — Selective pulmonary vasodilation reduces RV afterload; ESC 2021 HF Class IIb; wean slowly to avoid rebound PH
7. inhaled epoprostenol 50 ng/kg/min nebulized INH continuous (prostacyclin_inhaled, first line) — Inhaled prostacyclin alternative to iNO; selective pulmonary vasodilation; lower cost than iNO
8. furosemide CAUTIOUS — 20-40 mg IV ONLY if clearly volume-overloaded (rising CVP without CO improvement) IV as needed (loop_diuretic, comorbidity specific) — Over-diuresis worsens RV preload; use only if clearly congested + monitor CVP + CO closely

Setting playbook (outpatient) — Long-term PAH or biventricular HF management; transplant/LVAD listing if advanced; pulmonary rehab maintenance
9. continue PAH therapy sildenafil + ambrisentan combination if dual therapy indicated PO as scheduled — PAH confirmed (AMBITION trial — combination therapy)
10. continue 4-pillar GDMT if biventricular ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — Biventricular HFrEF (ACC/AHA 2022 HF)

Non-pharmacologic actions:
- Pulmonary + cardiac rehab maintenance
- Influenza + pneumococcal + RSV vaccines
- Pregnancy prevention in PAH patients (high mortality)
- Transplant listing if functional class III-IV despite max therapy

AVOID / contraindication checks:
- Avoid_isolated_lv_mcs_impella_cp_in_rv_failure (worsens RV by reducing LV filling — DanGer Shock context PMID 38587234)
- Avoid_over_resuscitation_in_rv_failure (worsens RV dilation + septal shift impairing LV filling)
- Avoid_aggressive_diuresis_in_rv_failure (reduces preload; only diurese if clearly overloaded)
- Wean_inhaled_no_or_epoprostenol_slowly (rebound PH on abrupt withdrawal)
- Avoid_pde5i_with_iv_nitrates_or_with_riociguat (severe hypotension)
- Milrinone_avoid_if_hypotensive (vasodilation worsens MAP)
- Vasopressin_preferred_second_pressor_in_pulmonary_htn (spares pulmonary vasculature)

Monitoring

Regimen monitoring:
- continuous arterial line for map (titrate vasopressor)
- pa catheter or picco for co cvp pcwp pvr (hemodynamic phenotyping)
- daily echo for rv function (TAPSE, RVFAC, septal position)
- q6h lactate and bmp (perfusion + renal congestion)
- hourly uop (avoid over-diuresis)
- continuous telemetry (RV-dependent arrhythmias)
- spo2 with paO2 if intubated (hypoxemia drives PVR)

Setting (outpatient) monitoring:
- Quarterly RHC/echo
- Annual BMP + NT-proBNP

Follow-up plan: PAH-specific therapy escalation if PH crisis; cardiac rehab; advanced HF + transplant/LVAD eval if recurrent RV decompensation
- Close-out criterion: PAH clinic + advanced HF eval booked

Monitoring phase: Continuous arterial line, CVP/PA catheter if available, hourly UOP, daily echo until stable, q6h lactate + BMP, telemetry

Disposition

Current setting: outpatient — Long-term PAH or biventricular HF management; transplant/LVAD listing if advanced; pulmonary rehab maintenance

Disposition criteria:
- Long-term continuation; cross-link to cardio.idiopathic-pulmonary-arterial-hypertension.v1 or chronic HF engine

Escalation triggers (move to higher acuity):
- Worsening WHO class → escalate to triple PAH therapy
- Recurrent RV decompensation → transplant evaluation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] RV-predominant cardiogenic shock with persistent lactate ≥4, MAP <65 despite NE + vasopressin + dobutamine + iNO
- [LIFE_THREATENING] Known PAH + new syncope/pre-arrest/lactate rise + severely elevated PA pressure on echo
- [LIFE_THREATENING] Inferior STEMI + V4R ST elevation + hypotension + clear lungs → RV-MI with shock

Citations

- ESC 2021 HF + 2022 ACC/AHA HF + Konstantinides ESC 2019 PE [PMID:34447992](https://pubmed.ncbi.nlm.nih.gov/34447992/)
- Cited evidence (PMID 35363499) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 38264914) [PMID:38264914](https://pubmed.ncbi.nlm.nih.gov/38264914/)
- Cited evidence (PMID 21366472) [PMID:21366472](https://pubmed.ncbi.nlm.nih.gov/21366472/)
- Cited evidence (PMID 11386262) [PMID:11386262](https://pubmed.ncbi.nlm.nih.gov/11386262/)

Last reconciled with current guidelines: 2026-05-14.
References