What are the symptoms of right heart failure?

Right Heart Failure Symptoms

Right heart failure presents predominantly with systemic venous congestion manifesting as jugular venous distension, peripheral edema, hepatomegaly, and ascites, rather than the pulmonary symptoms seen in left-sided failure. 1

Cardinal Signs of Systemic Venous Congestion

The hallmark clinical presentation involves evidence of elevated right atrial and systemic venous pressures:

• Jugular venous distension (JVD) with elevated jugular venous pressure is the most prominent sign, reflecting increased right atrial pressure 1, 2
• Peripheral edema, particularly ankle swelling that progresses upward as the condition worsens 1, 2
• Hepatomegaly from hepatic congestion, which may be tender on palpation 1, 2
• Ascites develops in advanced cases as fluid accumulation becomes generalized 1, 2

Hemodynamic Manifestations

Right heart failure produces distinct circulatory compromise:

• Hypotension with systolic blood pressure often <90 mmHg due to reduced cardiac output 1, 3
• Cool extremities from peripheral vasoconstriction and impaired tissue perfusion 1, 3
• Low urine output (<0.5 mL/kg/h) reflecting inadequate renal perfusion 1
• Low cardiac output syndrome without pulmonary congestion, distinguishing it from left-sided failure 1

Respiratory and Systemic Symptoms

While less prominent than in left heart failure, patients experience:

• Dyspnea and fatigue, though typically less severe than left-sided failure unless there is concurrent pulmonary hypertension 1, 2
• Abdominal distension from hepatomegaly and ascites 1
• Weakness from reduced systemic perfusion 1
• Nausea and poor appetite from hepatic and gastrointestinal congestion 4

Physical Examination Findings

A systematic examination reveals specific right-sided abnormalities:

• Left parasternal lift from right ventricular hypertrophy 1
• Accentuated pulmonary component of S2 if pulmonary hypertension is present 1
• Pansystolic murmur of tricuspid regurgitation 1
• Right ventricular S3 gallop 1
• Hepatojugular reflux demonstrating elevated central venous pressure 2

Underlying Pathophysiology

Understanding the mechanism helps recognize the clinical pattern:

• The most common cause is left ventricular failure leading to pulmonary hypertension, which then causes right ventricular dysfunction 1
• Right ventricular dysfunction results in inability to maintain systemic venous pressure sufficiently low to guarantee optimal venous return 2
• This creates systemic venous hypertension with resultant peripheral fluid accumulation 2
• The right ventricle is particularly susceptible to acute changes in afterload due to its thin-walled structure 3

Critical Diagnostic Considerations

Diagnosis requires elevated right atrial/venous pressure signs PLUS at least one of: (1) compromised RV function, (2) pulmonary hypertension, or (3) peripheral edema with hepatomegaly. 2

• Lung sounds are typically normal in isolated right heart failure, unlike left-sided failure 1
• The absence of pulmonary rales helps distinguish pure right heart failure from biventricular failure 1
• ECG may show right ventricular hypertrophy (87% sensitivity) and right axis deviation (79% sensitivity) 1
• Echocardiography is essential to confirm right ventricular dysfunction and assess pulmonary pressures 2, 5

Common Clinical Pitfalls

• Do not assume pulmonary symptoms are absent—patients with right heart failure secondary to pulmonary hypertension may have dyspnea 1
• Peripheral edema alone is nonspecific—must be accompanied by elevated JVP to confirm right heart failure 1
• Right heart failure often coexists with left heart failure, making pure right-sided presentations less common in clinical practice 1
• Early recognition is crucial as delayed diagnosis worsens prognosis and may lead to irreversible end-organ damage 2