What are the clinical presentations and management of right-sided heart failure?

From the Guidelines

Right-sided heart failure presents with symptoms of systemic venous congestion, including peripheral edema, jugular venous distention, hepatomegaly, ascites, and fatigue, and its management focuses on treating the underlying cause while providing symptomatic relief, with diuretics, particularly loop diuretics, being first-line treatments to reduce fluid overload 1. The clinical presentation of right-sided heart failure can vary depending on the underlying cause, but common symptoms include peripheral edema, jugular venous distention, hepatomegaly, ascites, and fatigue. The management of right-sided heart failure involves treating the underlying cause, such as left-sided heart failure, pulmonary hypertension, right ventricular infarction, or congenital heart disease, while providing symptomatic relief.

• Key management strategies include:
  • Diuretics, particularly loop diuretics like furosemide (20-80mg daily) or torsemide (10-20mg daily), to reduce fluid overload 1
  • Sodium restriction to 2-3g daily to minimize fluid retention 1
  • For patients with pulmonary arterial hypertension causing right heart failure, specific therapies include phosphodiesterase-5 inhibitors (sildenafil 20mg three times daily), endothelin receptor antagonists (bosentan 62.5mg twice daily for 4 weeks, then 125mg twice daily), or prostacyclin analogs 1
  • Oxygen therapy for hypoxemic patients to prevent further pulmonary vasoconstriction
  • In advanced cases, digoxin (0.125-0.25mg daily with careful monitoring of levels) may improve contractility 1
  • For right heart failure due to left heart failure, standard heart failure therapies apply, including ACE inhibitors, beta-blockers, and aldosterone antagonists 1 The most recent and highest quality study, published in 2018 in the journal Circulation, provides guidance on the assessment and management of right-sided heart failure, emphasizing the importance of treating the underlying cause and providing symptomatic relief 1. Regular monitoring of weight, renal function, and electrolytes is essential during treatment to prevent complications from diuretic therapy. Mechanical circulatory support or heart transplantation may be considered in refractory cases.
• It is essential to note that the management of right-sided heart failure should be individualized based on the underlying cause and the patient's specific needs, and that a multidisciplinary approach, including cardiologists, pulmonologists, and other specialists, may be necessary to optimize care 1.

From the Research

Clinical Presentation of Right-Sided Heart Failure

• Right heart failure (RHF) is a clinical syndrome characterized by symptoms and signs caused by dysfunction and/or overload of the right heart structures, predominantly the right ventricle (RV) 2
• The most prominent clinical signs of RHF comprise swelling of the neck veins with an elevation of jugular venous pressure and ankle oedema 2
• As the situation worsens, fluid accumulation becomes generalised with extensive oedema of the legs, congestive hepatomegaly and eventually ascites 2
• Diagnosis of RHF requires the presence of signs of elevated right atrial and venous pressures, including dilation of neck veins, with at least one of the following criteria: (1) compromised RV function; (2) pulmonary hypertension; (3) peripheral oedema and congestive hepatomegaly 2

Management of Right-Sided Heart Failure

• Diuretics are used to reduce symptoms, prolong life, or both, in patients with congestive heart failure (CHF) by inducing sodium and water excretion, leading to decreased cardiac preload and wall tension, and an effective decrease of symptomatic pulmonary and systemic congestion 3
• Angiotensin-converting enzyme (ACE) inhibitors can cause hemodynamic and neurohormonal changes that lead to a reduction of preload and afterload, decreasing symptoms of heart failure 3
• ACE inhibitors significantly decrease CHF mortality, and might also deter the development of overt heart failure in some asymptomatic patients with left ventricular dysfunction 3
• Treatment of heart failure with reduced left ventricular ejection fraction (HFrEF) involves identifying and treating underlying and precipitating causes, and using diuretics, ACE inhibitors, and β-blockers 4

Identification of Heart Failure Exacerbation

• The extent of jugular venous distension and lower extremity edema are the best tools from history and physical examination to identify heart failure exacerbation 5
• The presence and extent of jugular venous distension and lower extremity edema, and a positive hepatojugular reflux are better than other signs and symptoms in identifying severity of HF exacerbation among patients with EF ≤ 30% 5
• Right-sided heart failure (RHF) occurs from impaired contractility of the right ventricle caused by pressure, volume overload, or intrinsic myocardial contractile dysfunction 6