What is the treatment for acute right-sided heart failure?

From the Guidelines

The treatment for acute right-sided heart failure should prioritize addressing the underlying cause, improving right ventricular function, and reducing congestion, with initial management including supplemental oxygen and careful fluid management, as recommended by the most recent guidelines 1.

Key Considerations

• Initial management includes supplemental oxygen to maintain adequate saturation and careful fluid management.
• Diuretics such as furosemide may be used to reduce volume overload, but must be administered cautiously to avoid excessive preload reduction.
• Vasopressors like norepinephrine may be needed to maintain systemic blood pressure.
• Inotropic support with dobutamine or milrinone can improve right ventricular contractility.
• For patients with pulmonary hypertension contributing to right heart failure, pulmonary vasodilators such as inhaled nitric oxide, sildenafil, or prostacyclin analogs may be beneficial.

Treatment Approach

• The aim of therapy is to correct hypoxia and increase cardiac output, renal perfusion, sodium excretion, and urine output, as outlined in the European Society of Cardiology guidelines 1.
• Mechanical support with an intra-aortic balloon pump or right ventricular assist device might be necessary in severe cases unresponsive to medical therapy.
• The underlying pathophysiology involves right ventricular pressure or volume overload leading to ventricular dilation, tricuspid regurgitation, and systemic venous congestion, so treatment aims to interrupt this cycle by improving contractility and reducing afterload while maintaining adequate preload.

Specific Recommendations

• Norepinephrine is the recommended vasopressor when mean arterial pressure needs pharmacologic support 1.
• Dobutamine might be used in patients with no beta-blockers, while levosimendan may be used as an alternative, especially in patients on beta-blockers on admission 1.
• Percutaneous left ventricular assist devices have been used in patients not responding to standard treatment, but the current experience and evidence are limited 1.

From the FDA Drug Label

Milrinone lactate injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure. The treatment for acute right-sided heart failure is not explicitly stated in the provided drug labels. However, milrinone (IV) is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure.

• The provided drug labels do not differentiate between left and right-sided heart failure.
• Milrinone (IV) may be used to treat heart failure, but its effectiveness for right-sided heart failure specifically is not directly addressed in the labels 2 2.

From the Research

Treatment for Acute Right-Sided Heart Failure

The treatment for acute right-sided heart failure involves managing the condition to optimize right-sided filling pressures and reduce afterload. Some key points to consider include:

• Management of RV failure is directed at optimizing right-sided filling pressures and reducing afterload 3
• Successful management requires reversal of any conditions that heighten pulmonary vascular tone and the use of selective pulmonary vasodilators at doses that do not induce systemic hypotension or worsening of oxygenation 3
• Systemic systolic arterial pressure should be kept close to RV systolic pressure to maintain RV perfusion 3
• When these efforts fail, the judicious use of inotropic agents may help improve RV contractility enough to maintain cardiac output 3
• Extracorporeal life support is increasingly being used to support patients with acute RV failure who fail to respond to medical management while the underlying cause of their RV failure is addressed 3

Use of Diuretics in Acute Heart Failure

Diuretics, such as furosemide, play a crucial role in the treatment of acute heart failure, including right-sided heart failure. Key points to consider include:

• Early administration of furosemide is associated with improved outcomes, including lower 30-day heart failure hospitalizations and composite of heart failure hospitalizations or cardiovascular death 4
• Door-to-furosemide time is an important factor, with earlier administration (≤1 hour) associated with better outcomes 4, 5, 6
• Furosemide treatment can help relieve symptoms of congestion, such as dyspnea and peripheral edema, which are common in patients with heart failure 7

Additional Considerations

Other factors to consider in the treatment of acute right-sided heart failure include:

• The importance of addressing the underlying cause of the condition, such as pulmonary embolism or right-sided myocardial infarction 3
• The need for close monitoring and adjustment of treatment as needed to optimize outcomes 3, 5, 6
• The potential use of alternative treatments, such as ultrafiltration or natriuretic peptides, in patients who do not respond to traditional diuretic therapy 7