Right Heart Failure Due to Pulmonary Embolism in Patients Treated in Emergency Services: A Systematic Review

Abstract

Introduction: Right heart failure (RHF) secondary to pulmonary embolism (PE) is a severe clinical condition frequently associated with high morbidity and mortality in emergency care. Early detection of right ventricular (RV) dysfunction is crucial for accurate risk stratification and timely management. Aim: To systematically review the scientific literature on diagnostic methods, therapeutic approaches, and clinical outcomes of patients with RHF due to PE treated in emergency and urgent care settings. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Searches were performed in PubMed, Embase, SciELO, and BVS databases for studies published between 2019 and 2024. Eligible studies included original research, systematic reviews, and meta-analyses addressing RHF secondary to PE. Data on diagnostic modalities, treatment strategies, and outcomes were extracted and synthesized qualitatively. Results: A total of 450 records were identified, and 14 studies met the inclusion criteria. Echocardiography was the most common diagnostic method, with parameters such as RV/LV diameter ratio, tricuspid annular plane systolic excursion (TAPSE), and RV wall hypokinesia associated with increased mortality and hemodynamic instability. Computed tomography and biomarkers (troponin, BNP/NT-proBNP) provided complementary prognostic information. Patients with RV dysfunction had up to a twofold increase in all-cause mortality and a fourfold increase in PE-related death. Anticoagulation was universally recommended as first-line therapy, while the benefit of thrombolysis in hemodynamically stable patients remains controversial due to bleeding risk. Conclusion: Right ventricular dysfunction in patients with pulmonary embolism is a strong predictor of adverse outcomes in emergency settings. Echocardiography should be systematically used for early risk assessment, supported by CT and biomarkers when available. Despite therapeutic advances, significant evidence gaps persist regarding optimal management of submassive PE and the use of advanced support therapies, highlighting the need for robust clinical trials.