Management of Elevated Right Heart Pressure

Diagnostic Approach

A comprehensive pulmonary hypertension workup should be initiated when right ventricular systolic pressure exceeds 45 mmHg on echocardiography, according to the American Heart Association 1
Laboratory evaluation should include complete blood count, comprehensive metabolic panel, thyroid function tests, NT-proBNP, and when indicated, autoimmune antibodies, as recommended by the American College of Cardiology 1
Imaging studies should include electrocardiogram, chest X-ray, pulmonary function tests, and either CT angiogram or V/Q scan to evaluate for thromboembolic disease, as suggested by the American Thoracic Society 1
Right heart catheterization is essential for definitive diagnosis, with pulmonary hypertension defined as mean pulmonary artery pressure >20 mmHg, according to the European Society of Cardiology 2

The American College of Cardiology recommends treatment that targets both symptom relief through decongestion and addresses the underlying cause of right ventricular dysfunction, with a strength of evidence rated as moderate 3
Diuretics are the primary treatment for fluid retention and peripheral edema in right-sided heart failure, as recommended by the Heart Failure Society of America 3
Oxygen therapy should be administered to maintain oxygen saturation above 90% in hypoxemic patients, according to the American Thoracic Society 3

The European Society of Cardiology recommends that pulmonary vasodilator therapies should be continued during the perioperative period in patients with PAH, with a strength of evidence rated as high 2
Intravenous epoprostenol has demonstrated survival benefit in PAH patients and should be considered for those with severe disease, as recommended by the American College of Chest Physicians 1
The American Heart Association suggests that primary focus should be on optimizing left heart function and reducing pulmonary venous congestion in patients with PH due to left heart disease, with a strength of evidence rated as moderate 4, 5
Diuretics should be optimized to reduce volume overload in patients with PH due to left heart disease, as recommended by the European Society of Cardiology 6

Short-acting inhaled pulmonary vasodilators (nitric oxide, aerosolized prostacyclins) may be reasonable to reduce elevated RV afterload and prevent acute decompensated right heart failure during high-risk procedures, according to the American College of Cardiology 2

Regular assessment of functional capacity and right ventricular function is essential, as recommended by the American Heart Association 3
Monitor for signs of end-organ damage, particularly renal and liver function, according to the European Society of Cardiology 3
Consider referral to a specialized pulmonary hypertension center for patients with severe or progressive disease, as suggested by the American Thoracic Society 4, 5

Avoid excessive fluid administration in patients with right heart failure as it may worsen RV distention and function, according to the European Heart Journal 7
Recognize that elevated pulmonary artery pressure is both a risk marker on its own and a risk modifier in the presence of comorbidities, as recommended by the American College of Cardiology 4, 5
Be aware that even mildly elevated pulmonary artery pressures are associated with evidence of right ventricular dysfunction and poor outcomes, according to the American Heart Association 5