Pitfalls

The main pitfall in the ED management of PH is not maintaining a high index of suspicion in the patient presenting with dyspnoea in the absence of an alternative cause of cardiorespiratory disease.

A patient with PH may present with symptoms that are very common in ED patients (e.g. dyspnoea, fatigue, chest pain, near syncope or syncope). The emergency physician should consider PH in the differential diagnosis for these symptoms. For example, a patient who presents to the ED with chest pain may be having an acute myocardial infarction for which sublingual glyceryl trinitrate (GTN) is appropriate; however if a patient with chest pain also has RV failure as a complication of PH, sublingual GTN may cause catastrophic hypotension and may be contraindicated.

A combination of investigations such as chest x-ray, ECG and point of care echocardiography may assist in differentiating between LV failure and RV failure at the bedside.