Right Heart Failure
Pulmonary Embolism in Pregnancy…and a PERC reminder
- Symptoms of RV failure are VAGUE; If you do not consider it, you will not diagnosis it!
- RV failure is rare… but bad. If RV failure requires pressors, mortality can increase to 60%.
- Most common cause = CHRONIC DISEASE + ACUTE INSULT
- RH failure follows an auto-aggravation pathway, following a vicious cycle.
- To treat: 1) Decrease RV afterload, 2) Augment RV contractility, 3) Optimize preload and 4) Maintain MAP
Pulmonary Embolism in Pregnancy…and a PERC reminder
- PERC Rule: Apply to patients who are Well’s Low or with whom clinical gestalt for PE is < 10%. This allows your post-test probability to be <1.8% if patient is PERC negative.
- No prior VTE; No unilateral leg swelling; No estrogens; No hemoptysis; No surgery/trauma requiring hospitalization within 4 wks: Age < 50 YO; HR < 100; SpO2 ≥ 95%
- To be negative must meet all 8 criteria!
- PERC Limitations:
- Patients excluded from PERC during the study:
- Cancer, thrombophilia, strong FHx of PTE, transient tachycardia, beta-blocker use; Hx of chronic hypoxia, amputations, massively obese
- Be careful applying PERC to patient who:
- Are at increased risk of VTE
- Have a limited vital sign exam
- Have a limited physical exam
- Patients excluded from PERC during the study:
- D-dimer in Pregnancy
- Risk of PE/DVT increase as pregnancy progresses
- Highest risk of VTE is in the postpartum state (up to 1 mo), especially in C/S patients
- D-dimer increases during pregnancy
- Trimester-adjusted dimer studies currently with very small sample sizes
- No established risk stratification tool validated in pregnancy
- However, if d-dimer is negative. It’s negative.