What is the next step in treatment for a 72-year-old female with normal left ventricular systolic function, grade II diastolic dysfunction, reduced right ventricular systolic function, and elevated right atrial pressure?

Management of Right Ventricular Dysfunction with Normal Left Ventricular Systolic Function

The next step in treatment for this 72-year-old female with normal left ventricular systolic function, grade II diastolic dysfunction, reduced right ventricular systolic function, and elevated right atrial pressure should be initiation of a beta-blocker or calcium channel blocker therapy to improve diastolic function and address right ventricular dysfunction.

Assessment of Current Cardiac Status

This patient presents with:

• Normal left ventricular systolic function (EF 71%)
• Grade II diastolic dysfunction (moderate)
• Reduced right ventricular systolic function (S' 5.11 cm/s)
• Elevated right atrial pressure (8 mmHg)
• Normal inferior vena cava with <50% collapse on inspiration
• No pericardial effusion
• No significant valvular abnormalities

Treatment Algorithm

Step 1: Address Diastolic Dysfunction

• Diastolic dysfunction impairs ventricular filling by diminishing relaxation or reducing compliance, leading to elevated filling pressures 1
• The hemodynamic consequences include elevation of ventricular filling, left atrial, pulmonary venous, and pulmonary capillary pressures 1
• For grade II diastolic dysfunction, medications that improve ventricular relaxation are indicated

Step 2: Target Right Ventricular Dysfunction

• Reduced right ventricular systolic function (TAPSE <16 mm) indicates RV systolic dysfunction 1
• The elevated right atrial pressure (8 mmHg) with reduced IVC collapse confirms right-sided pressure overload

Step 3: Medication Selection

• Beta-blockers (bisoprolol, carvedilol, or metoprolol succinate) are first-line agents for diastolic dysfunction 2, 3

  • Start at low dose: bisoprolol 1.25 mg once daily, carvedilol 3.125 mg twice daily, or metoprolol succinate 12.5-25 mg once daily
  • Titrate every 2 weeks as tolerated toward target doses 2

• Calcium channel blockers may be considered as alternatives 3, 4

  • Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) if there is concern about worsening right ventricular function

Step 4: Additional Measures

• Moderate sodium restriction to reduce fluid retention 2
• Consider fluid restriction of 1.5-2 L/day 2
• Implement daily weight monitoring with an action plan for weight gain >2 kg in 3 days 2
• Encourage regular, structured physical activity starting with low intensity 2

Monitoring Plan

• Monitor renal function and electrolytes, especially if diuretics are added 2
• Follow-up echocardiography to assess response to therapy
• Consider serial monitoring of natriuretic peptide levels to guide therapy 2

Important Considerations and Pitfalls

1. Avoid inappropriate medications:

   • NSAIDs can worsen fluid retention and should be avoided 2
   • Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) should be used cautiously in patients with reduced right ventricular function 2

2. Differentiate from systolic heart failure treatment:

   • Unlike systolic dysfunction, where ACE inhibitors, ARBs, and ARNI are cornerstone therapies, diastolic dysfunction with preserved ejection fraction responds better to beta-blockers and calcium channel blockers 3, 4
   • Positive inotropic agents and arterial vasodilators are generally not useful in heart failure due to diastolic dysfunction 3

3. Consider underlying causes:

   • Right ventricular dysfunction may be related to pulmonary hypertension, which itself can cause RV diastolic dysfunction 5
   • Diastolic abnormalities may occur before systolic dysfunction becomes evident 6

By addressing both the diastolic dysfunction and right ventricular impairment with appropriate medication therapy, the goal is to improve ventricular filling, reduce pulmonary congestion, and prevent further deterioration of right ventricular function.