Levels of suggested monitoring in a patient with PAH and RV dysfunction. The ward and level of monitoring will depend on the adverse prognostic factors as listed in box 3, with high-risk patients requiring advanced level monitoring at least in a level two ward or high dependency or intensive care unit
| Monitoring RV failure in a patient with PAH | Target aims |
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Clinical signs
: WHO functional class ECG Monitor daily weight, fluid balance, JVP, and signs of overload BP Renal and liver function BNP | Improvement Sinus rhythm, less tachycardia Negative fluid balance, JVP falling Target BP>90 mmHg, MAP>70 mmHg* Improving renal, liver function Fall in BNP during the hospital admission (if rechecked) |
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Baseline haemodynamic monitoring
: on level 1 ward Telemetry, non-invasive BP (as above), lactate SaO2 Echocardiographic signs: right atrial area, pericardial effusion, RV function Urine output (catheterise) Consider RHC (see below) | Lactate <2 mmol/L SaO2>90% Improved RV parameters (and PAP) Increased urine output. Urine output aim for >0.5 mL/kg/hour† |
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Advanced haemodynamic monitoring
: on level 2/3 ward Arterial line monitoring CVP,‡SvO2 reflects global oxygen delivery. Rising CVP with fall in CO or BP suggests RV failure Pulmonary artery catheter—may be useful but mainly now used in post-surgery or complex cases when accurate trends in PCWP and PVR needed. Risks of arrhythmias in PAH CO monitoring eg. LIDCO, PiCCO (or lactate, SvO2, liver/renal function) | Normal BP for each patient* CVP—aim for 8–12 mm Hg PAP, PVR, CO—useful trends but correlate with other markers Improved CO and SvO2 or surrogates for CO as listed |
Absolute CVP will depend on RV size and volume status/requirement for filling pressure.
*Be guided by signs of end organ perfusion (lactate, renal/liver function, SvO2).
†Fluid balance aim depends on recent balance, usual diuretic dose, renal function, BP.
‡CVP is equivalent to RAP in most settings but may be unreliable in torrential tricuspid regurgitation (which may be present).
BNP, brain natriuretic peptide; CO, cardiac output; CVP, central venous pressure; JVP, jugular venous pressure; LIDCO, lithium dilution CO; MAP, mean arterial pressure; PA, pulmonary arterial; PAH, pulmonary arterial hypertension; PCWP, pulmonary capillary wedge pressure; PiCCO, pulse index continuous CO; PVR, pulmonary vascular resistance; RAP, right atrial pressure; RHC, right heart catheterisation; RV, right ventricular; SaO2, arterial oxygen saturation; SvO2, mixed venous oxygen saturation; UO, urine output.