An integrated approach to the acutely decompensated RV requires assessment of the underlying cause (Fig 9
). After the initial history and physical, laboratory studies, including serum cardiac biomarkers, should be obtained along with an ECG and chest radiograph. Cardiac biomarkers will aid in the diagnosis of RV failure, as well as suggest conditions that might have been unsuspected, such as myocardial infarction, PE, and congestive heart failure. After these initial studies, a transthoracic echocardiogram can confirm the diagnosis of RV failure. Frequently, the echocardiogram will help triage patients into the following four groups: LV failure, RV failure with elevated pulmonary artery pressures, RV failure without elevated pulmonary artery pressures, and pericardial disease. The finding of LV failure should prompt an additional evaluation for acute myocardial infarction, left-sided cardiomyopathy, and valvular heart disease. The patients with RV failure and elevated pulmonary artery pressures should undergo workup for causes of pulmonary hypertension. RV failure without pulmonary hypertension suggests intrinsic RV disease, such as RV infarction, right-sided valvular heart disease, and right-sided cardiomyopathy. Finally, pericardial disease may require additional evaluation with cardiac MRI and right-heart catheterization.