Carolinas case conference - Dr. C. COx

Right Heart Failure

1. Symptoms of RV failure are VAGUE; If you do not consider it, you will not diagnosis it! 
2. RV failure is rare… but bad. If RV failure requires pressors, mortality can increase to 60%.
3. Most common cause = CHRONIC DISEASE + ACUTE INSULT
4. RH failure follows an auto-aggravation pathway, following a vicious cycle.
5. 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

1. 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.
   1. 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%
   2. To be negative must meet all 8 criteria!
2. PERC Limitations:
   1. Patients excluded from PERC during the study:
      1. Cancer, thrombophilia, strong FHx of PTE, transient tachycardia, beta-blocker use; Hx of chronic hypoxia, amputations, massively obese
   2. Be careful applying PERC to patient who:
      1. Are at increased risk of VTE
      2. Have a limited vital sign exam
      3. Have a limited physical exam
3. D-dimer in Pregnancy
   1. Risk of PE/DVT increase as pregnancy progresses
   2. Highest risk of VTE is in the postpartum state (up to 1 mo), especially in C/S patients
   3. D-dimer increases during pregnancy
      1. Trimester-adjusted dimer studies currently with very small sample sizes
      2. No established risk stratification tool validated in pregnancy
      3. However, if d-dimer is negative. It’s negative.

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