75 y/o M PMHx of ESRD on HD, pulmonary HTN, HLD presents to the ED with 1 week of progressive fatigue and SOB. Pt on 2L NC home O2 but requiring 4L NC in the ED to maintain saturation > 95%. On exam, pt with increased WOB and RR > 20. Lungs are CTA. Cardiac exam shows RRR with mild JVD, abdominal distention and +1 pitting edema B/L. POCUS was performed and is shown below. What is the diagnosis?
Answer: Right Heart Strain from Pulmonary Hypertension
- Signs in POCUS that are indicative of R heart strain:
- D-sign: septal flattening seen in the parasternal short orientation that is indicative of increased RV pressures
- McConnel’s Sign: seen in the apical 4 chamber view. R ventricular free wall akinesis with sparing of the apex (apical hyperkinesis)
- Increased RV:LV ratio, typically should be ⅓:⅔
- Decreased TAPSE: measurement of the vertical motion of the tricuspid valve in the apical 4 chamber view (normal > 16 mm)
- Causes of R- Heart Strain:
- Pulmonary Embolism
- Pulmonary hypertension
- Biventricular failure
- R sided heart failure
- Valvular dysfunction (Acute TR)
- Pulmonary Hypertension:
- Type 1: primary arterial pulmonary HTN
- Type 2: PH due to L heart failure
- Type 3: PH due to lung disease
- Type 4: PH due to chronic thromboembolic disease
- Type 5: idiopathic PH
- Acute Treatment for PH includes
- Optimize RV preload- patients typically euvolemic or hypervolemic and do not respond well to rapid shifts in fluid status (usually avoid fluids). If hypovolemia/sepsis consider small 250 ml boluses with frequent reassessments
- Improve cardiac output: consider early ionotropes
- Reduce RV afterload: avoid hypoxia, acidosis, hypercapnia
- Treat arrhythmias: most common is SVT followed by afib/flutter
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