From the Guidelines
Treatment of elevated right ventricular systolic pressure (RVSP) should focus on addressing the underlying cause while managing symptoms, with a primary approach involving diuretics and pulmonary vasodilators, as well as oxygen therapy to maintain oxygen saturation above 90%. The management of elevated RVSP requires a comprehensive approach, including diagnosis and characterization of the disease phenotype, assessment of functional class, and evaluation of co-morbid conditions 1. Patients with elevated RVSP should undergo a thorough diagnostic workup, including echocardiogram, pulmonary function tests, and screening for underlying conditions such as congenital heart disease, autoimmune diseases, and thromboembolic disease.
Key components of treatment include:
- Diuretics, such as furosemide (20-80mg daily) or spironolactone (25-100mg daily), to reduce fluid overload and decrease right heart strain
- Pulmonary vasodilators, including phosphodiesterase-5 inhibitors (sildenafil 20mg three times daily), endothelin receptor antagonists (bosentan 62.5-125mg twice daily), or prostacyclin analogs (epoprostenol, treprostinil) for more severe cases
- Oxygen therapy to maintain oxygen saturation above 90%
- Anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants for RVSP due to chronic thromboembolic disease
- Consideration of medications like ACE inhibitors, beta-blockers, or aldosterone antagonists if left heart disease is contributing
In critically ill patients, management may involve intensive care unit (ICU) admission, with careful selection of inotropes and vasopressors to maintain systemic vascular resistance (SVR) greater than pulmonary vascular resistance (PVR) 1. Inhaled nitric oxide (iNO) may be used to acutely decrease PVR and improve cardiac output, and phosphodiesterase inhibitors may be employed as replacement therapy upon weaning from iNO. Regular echocardiographic monitoring is essential to assess treatment response and guide adjustments to therapy.
From the Research
Treatment of Elevated Right Ventricular Systolic Pressure (RVSP)
Elevated RVSP is a common condition among patients with heart failure (HF) and pulmonary hypertension (PH) 2, 3. The treatment of elevated RVSP depends on the underlying cause and severity of the condition.
Causes and Classification of Pulmonary Hypertension
Pulmonary hypertension is classified into five clinical subgroups: pulmonary arterial hypertension (PAH), PH due to left-sided heart disease, PH due to chronic lung disease, chronic thromboembolic PH (CTEPH), and PH with an unclear and/or multifactorial mechanisms 3.
Diagnostic Tests and Treatment Options
Diagnostic tests for PH include electrocardiography, chest radiography, pulmonary function tests, and transthoracic echocardiography 3. Right-sided heart catheterization is essential for accurate diagnosis and classification. Treatment options for PH depend on the underlying cause and severity of the condition. For example, surgical pulmonary endarterectomy is the treatment of choice for eligible patients with CTEPH, while targeted treatments such as phosphodiesterase type 5 inhibitors and endothelin receptor antagonists are licensed for patients with PAH 3.
Management of Heart Failure
In patients with heart failure, diuretics are commonly used to manage hypervolemia 4. The choice of diuretic depends on the patient's clinical situation and the presence of other co-morbidities. Azosemide and torasemide have been shown to cause a significant reduction in brain natriuretic peptide (BNP) level and edema 4.
Factors Influencing RVSP
RVSP increases progressively with age, and the normal range of RVSP varies according to age 5. Multivariate analysis has shown that age, mitral diastolic early-to-late filling velocity ratio, ejection fraction, aortic size, and early mitral filling velocity/early diastolic mitral annular velocity are significant independent variables influencing RVSP 5.
Perioperative Pulmonary Risk Assessment
RVSP has been shown to have limited efficacy as a standalone predictor of 30-day postoperative pulmonary complications (PPC) in patients with PH 6. The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score has been shown to be associated with 30-day PPC risk, but the combination of RVSP and ARISCAT scoring yielded only marginal improvements in predictive accuracy 6.
- Key points to consider when treating elevated RVSP:
- Underlying cause and severity of the condition
- Diagnostic tests such as electrocardiography, chest radiography, pulmonary function tests, and transthoracic echocardiography
- Treatment options such as diuretics, targeted treatments, and surgical pulmonary endarterectomy
- Factors influencing RVSP such as age, mitral diastolic early-to-late filling velocity ratio, ejection fraction, aortic size, and early mitral filling velocity/early diastolic mitral annular velocity
- Perioperative pulmonary risk assessment using RVSP and ARISCAT scoring