What is the basic work-up for a new diagnosis of mild congestive heart failure (CHF) and moderately elevated right ventricular (RV) pressure in an 84-year-old patient with pneumonia, mild brain natriuretic peptide (BNP) elevation, cardiomegaly, small pleural effusions, mild aortic regurgitation (AR), and mild tricuspid regurgitation (TR)?

From the Guidelines

For this 84-year-old patient with pneumonia who has findings suggestive of new mild congestive heart failure (CHF) and moderately elevated right ventricular (RV) pressure, I recommend a basic work-up that includes a thorough history and physical examination, chest radiographs, electrocardiogram, and echocardiography, as outlined in the 2009 ACC/AHA guidelines for the diagnosis and management of heart failure in adults 1. The initial evaluation should prioritize assessing the patient's volume status, systemic perfusion, and the contribution of precipitating factors and/or comorbidities, such as pneumonia, to the development of CHF. Key components of the work-up include:

• Chest radiographs to assess for cardiomegaly, pleural effusions, and pulmonary edema
• Electrocardiogram to evaluate for arrhythmias or ischemic changes
• Echocardiography to quantify the RV pressure elevation, evaluate for potential causes such as pulmonary hypertension, and assess for valvular abnormalities like mild aortic regurgitation (AR) and mild tricuspid regurgitation (TR)
• Measurement of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) to support the diagnosis of HF, as recommended in the guidelines 1
• Identification of potential precipitating factors for acute HF, such as infections, and addressing these factors as part of the treatment plan 1 The patient's treatment should focus on addressing fluid overload, managing symptoms, and optimizing systemic perfusion, with careful monitoring of fluid intake and output, vital signs, and clinical signs of congestion. The guidelines recommend administering oxygen therapy to relieve symptoms related to hypoxemia, and using intravenous loop diuretics to treat significant fluid overload, with careful monitoring of urine output and signs of congestion 1. By following this approach, the patient's CHF and RV pressure elevation can be effectively managed, while also addressing the underlying pneumonia and other comorbidities.

From the Research

Basic Work-up for Mild Congestive Heart Failure (CHF) and Moderately Elevated Right Ventricular (RV) Pressure

The basic work-up for a new diagnosis of mild congestive heart failure (CHF) and moderately elevated right ventricular (RV) pressure in an 84-year-old patient with pneumonia, mild brain natriuretic peptide (BNP) elevation, cardiomegaly, small pleural effusions, mild aortic regurgitation (AR), and mild tricuspid regurgitation (TR) includes:

• A thorough physical examination and basic, noninvasive evaluation to establish the diagnosis of heart failure and design an optimal treatment regimen 2
• Assessment of RV function and RV-arterial coupling using simplified methods such as echocardiographic and cardiac MRI approaches 3
• Measurement of brain natriuretic peptide (BNP) levels to evaluate the severity of heart failure 4
• Chest X-ray and echocardiography to evaluate cardiac function and structure 4

Treatment Options

Treatment options for mild CHF and moderately elevated RV pressure may include:

• Digitalis and diuretics to manage symptoms and improve cardiac function 2
• Vasodilators and ACE inhibitors to reduce afterload and improve cardiac function 2
• Beta blockers to inhibit sympathetic activity and reduce the risk of disease progression 5
• Selective pulmonary vasodilators to reduce pulmonary vascular tone and improve RV function 6
• Inotropic agents to improve RV contractility and maintain cardiac output 6

Management of RV Failure

Management of RV failure is directed at optimizing right-sided filling pressures and reducing afterload, and may include:

• Reversal of conditions that heighten pulmonary vascular tone 6
• Use of selective pulmonary vasodilators at doses that do not induce systemic hypotension or worsening of oxygenation 6
• Maintenance of systemic systolic arterial pressure close to RV systolic pressure to maintain RV perfusion 6