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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Right-sided heart failure

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Acute RV failure with hypotension, syncope, hypoxaemia, rising lactate or suspected PE/RV infarction requires immediate ABCDE care, senior cardiology/critical-care help, urgent echo and cause-specific reperfusion or support.

Synopsis

Recognise systemic venous congestion and acute RV shock, identify the cause and balance preload, afterload and contractility without reflex fluid or vasodilator harm.

  • Right-sided HF causes raised systemic venous pressure: raised JVP, peripheral oedema, ascites, hepatomegaly, early satiety and congestive renal/liver dysfunction.
  • Common drivers are left-sided HF, pulmonary hypertension or lung disease, acute PE, RV infarction, tricuspid/pulmonary valve disease, cardiomyopathy and constrictive pericardial disease.
  • Acute RV failure can present with shock and clear lungs; do not exclude cardiac shock because crackles are absent.
  • Treat the cause while balancing RV preload: severe underfilling may justify a small monitored fluid challenge, but routine repeated boluses worsen dilation and septal shift when congestion is present.
  • Use loop diuretic for systemic congestion, watching renal function and perfusion; venous congestion itself can drive cardiorenal dysfunction.
  • Avoid nitrates and other preload-reducing drugs in hypotensive RV infarction; restore coronary flow urgently through the ACS pathway.
  • Pulmonary vasodilators are disease-specific specialist therapy, not empirical treatment for undifferentiated RV failure and can be harmful in some left-heart or lung-disease phenotypes.
  • Refractory shock needs expert vasoactive therapy and early mechanical-support/advanced-centre discussion.

Key red flags

Acute RV shock

Hypotension, cool peripheries, oliguria, confusion and raised JVP, sometimes with clear lungs; rising lactate signals worsening output.

RV infarction

Inferior MI with hypotension, raised JVP and relatively clear lungs; right-sided ECG changes and echo support the diagnosis.

Pulmonary embolism

Sudden dyspnoea, pleuritic pain, syncope, hypoxaemia or shock with RV strain requires the NICE PE diagnostic and reperfusion pathway.

Investigation priorities

01
12-lead ECG including right-sided leads when RV infarction suspectedFirst step

Identify inferior/RV MI, RV strain, AF or other arrhythmia.

Management branches

First-lineAcute RV failure

Raised JVP with hypoperfusion, hypoxaemia or shock

  1. Start ABCDE, cardiac monitoring, blood gas/lactate and urgent echo; call cardiology and critical care.
  2. Treat hypoxia, acidosis and the driver: activate ACS reperfusion for RV infarct or NICE PE diagnosis/reperfusion for suspected high-risk PE.
  3. Assess preload with examination and echo; use only a small monitored fluid challenge if clearly underfilled and stop if congestion/output worsens.
  4. Avoid empirical nitrate or aggressive ventilation pressures that can collapse preload in a hypotensive, preload-dependent patient.

Key medicines

FurosemideFor chronic oedema a common oral start is 20–40 mg in the morning; acute congestion commonly starts 20–40 mg IV if loop-naive, with higher response-led IV dosing when already exposed.Over-diuresis can reduce RV preload/output; under-diuresis leaves renal/hepatic congestion. Monitor BP, urine, weight, creatinine, sodium, potassium and magnesium.
NoradrenalineThe cited ready-to-use SmPC, licensed for adults weighing over 50 kg, starts noradrenaline base at 0.05–0.15 micrograms/kg/min by central IV infusion pump, titrated in critical care to adequate MAP/perfusion.For this product use a central venous catheter and preferably arterial BP monitoring; concentrations and labels differ between preparations. Watch for excessive vasoconstriction, arrhythmia, ischaemia and extravasation, and treat the cause concurrently.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG106: Chronic heart failure in adultsCongestion, cause, monitoring and advanced-HF referral.
  • ESC 2021 Guidelines for acute and chronic heart failureRV-failure haemodynamic framework.
  • ESC 2023 Guidelines for acute coronary syndromesRV-infarction reperfusion and haemodynamic-complication context.
  • NICE NG158: Venous thromboembolic diseasesPE diagnostic and treatment route.
  • Noradrenaline 0.08 mg/mL SmPCLicensed weight-based infusion dosing.
  • Dobutamine 5 mg/mL SmPCLicensed infusion dose range.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom