Signs of Right Heart Strain
Right heart strain manifests clinically through elevated jugular venous pressure, peripheral edema, and hepatomegaly—these three findings are the most reliable clinical indicators according to the American Heart Association and should guide your initial assessment. 1, 2
Clinical Signs
Cardiovascular Examination
- Elevated jugular venous pressure (JVP) is the cardinal sign and most reliable indicator of right heart strain 3, 1, 2
- Right ventricular heave palpable at the left sternal border indicates RV pressure overload 2
- Loud P2 sound from forceful pulmonary valve closure reflects pulmonary hypertension 2
- S3 or S4 gallop heard over the right ventricle suggests RV dysfunction 3, 2
- Tricuspid regurgitation murmur may be present, though this is subjective and potentially misleading 3
- Large V waves in the jugular venous pulse indicate significant tricuspid regurgitation 2
Systemic Congestion Signs
- Peripheral edema, particularly in ankles and legs, worsening with disease progression 3, 1, 2
- Hepatomegaly from hepatic congestion, causing epigastric fullness and pain 3, 1, 2
- Ascites in advanced cases indicates severe right-sided failure 3, 1, 2
- Dependent edema in gravity-dependent areas 3
Advanced Manifestations
- Hypotension with low pulse pressure in severe cases, particularly with right ventricular infarction 3
- Hypoxia and peripheral cyanosis occur in advanced right heart failure 1, 2
- Oliguria from decreased renal perfusion 1
- Confusion and altered mental status from tissue hypoperfusion in severe cases 1
- Cachexia from poor nutrient absorption and systemic inflammation 2
ECG Findings
New ECG signs of RV strain have limited sensitivity but are useful when present 3:
- T-wave inversion in leads V1-V4 3
- QR pattern in V1 lead 3
- Classic S1Q3T3 pattern 3
- Incomplete or complete right bundle-branch block 3
- Low QRS voltage, generalized T-wave flattening, atrial abnormalities, or atrial fibrillation 3
Echocardiographic Signs
Direct RV Assessment
- RV dilatation with RV:LV ratio ≥0.9 indicates significant strain 4, 5
- RV hypokinesis, particularly with preserved apical function (McConnell's sign) suggests pulmonary embolism 4
- Decreased tricuspid annular plane systolic excursion (TAPSE) reflects impaired RV systolic function 4
- Decreased S' velocity on tissue Doppler imaging 4
- RV free wall strain <20% on speckle tracking indicates impaired function 6, 4
Septal Changes
- Interventricular septal bowing (leftward shift) from RV pressure overload—the "D-sign" in diastole 2, 4, 7
- Paradoxical septal motion ("dip-plateau phenomenon") 3
Secondary Findings
- Tricuspid regurgitation with elevated velocity 4
- Elevated pulmonary artery systolic pressure (>35-40 mmHg) 4
- Pulmonary artery mid-systolic notching on Doppler 4
- 60/60 sign (pulmonary acceleration time <60 ms and peak velocity <60 cm/s) 4
- Dilated inferior vena cava and hepatic veins with restricted respiratory variation 3
- RA and LA enlargement with normal ventricular appearance 3
Important caveat: Right atrial strain (sum of RA strain <30.2%) provides additive prognostic value beyond RV assessment alone, and patients with both impaired RV and RA function have the worst outcomes 6.
CT Findings
CT pulmonary angiography is highly sensitive (88%) but only moderately specific (39%) for RV strain compared to echocardiography 5:
- RV:LV ratio ≥0.9 is the primary CT criterion 7, 5
- Interventricular septal bowing toward the left ventricle 7, 5
- Right atrial enlargement is 100% predictive of RV strain on subsequent echocardiography 7
- Hepatic vein reflux indicates elevated right-sided pressures 7
Critical distinction: RV strain on both CT and echocardiography predicts 30% event rate, versus only 3-4% when strain is absent on both modalities 5. Echocardiography adds prognostic value beyond CT alone 5.
Invasive Hemodynamic Signs
- "Dip and plateau" or "square root" sign in RV pressure curve (seen in constrictive physiology) 3
- Equalization of LV/RV end-diastolic pressures within 5 mmHg 3
- Elevated mean right atrial pressure correlates with RA strain 6
- Elevated RV end-diastolic pressure 6
Biomarkers
- Elevated BNP or NT-proBNP reflects RV myocardial stretch and has high negative predictive value (94-100%) for excluding adverse outcomes 3
- Elevated cardiac troponins (troponin T >0.01 ng/mL or troponin I >0.5 ng/mL) indicate RV myocardial injury and predict worse prognosis 3
Context-Specific Presentations
Right Ventricular Infarction
The clinical triad of hypotension, clear lung fields, and raised JVP in inferior STEMI is specific but insensitive 3:
- ST-segment elevation in V4R is highly suggestive 3
- Q-waves and ST elevation in V1-V3 also suggest RV involvement 3
- Avoid vasodilators (opioids, nitrates, diuretics, ACE inhibitors) as they worsen hemodynamics 3
Pulmonary Embolism
Echocardiographic RV strain in the proper clinical context points toward PE and warrants directed management 3, 4:
- Normal cardiac ultrasound does not exclude PE 3
- RV strain may be absent in hemodynamically stable PE 3
- Alternative causes include acute RV infarct, pulmonic stenosis, and chronic pulmonary hypertension 3