Malignant asthma presenting as right heart failure

Studies are reported of four patients (all lifetime non-smokers) who presented with right heart failure as a consequence of unrelieved asthmatic airways obstruction. These patients demonstrated severe airways obstruction with crackles on auscultation and hypercapnia. As shown here, such a presentation, without the usual pattern of dyspnoea and wheeze, tends to obscure the diagnosis and delays effective treatment. In three of the patients, treatment to relieve airways obstruction improved gas exchange, and the heart failure resolved. In the remaining patient, improvement was limited, and death ensued from respiratory failure. In patients who present with right heart failure, a relationship with airways obstruction and respiratory failure should be considered and assessed by objective tests. Delays in the effective treatment of these patients may result in the progression of their disease to a stage at which airways obstruction no longer responds to medical therapy.