What are the diagnostic steps for right heart failure?

Diagnosing Right Heart Failure

Right heart failure diagnosis requires documented signs of elevated right atrial and venous pressures (elevated JVP, peripheral edema, hepatomegaly) plus evidence of either compromised RV function, pulmonary hypertension, or both on echocardiography. 1

Clinical Assessment

History

• Inquire specifically about: dyspnea, fatigue, exercise intolerance, orthopnea, and peripheral swelling 2, 3
• Document exposures: cardiotoxic agents (anthracyclines, trastuzumab, cyclophosphamide), mediastinal irradiation, alcohol use, and illicit drugs 4, 3
• Screen for underlying causes: coronary artery disease, hypertension, valvular disease, pulmonary disease, chronic thromboembolic disease, left heart failure, and sleep-disordered breathing 4, 1

Physical Examination

The physical examination must document specific signs of right heart failure: 4

• Elevated jugular venous pressure (most critical finding—has prognostic significance) 4, 1
• Peripheral edema (ankle swelling progressing to generalized edema) 1, 5
• Congestive hepatomegaly (with or without ascites in advanced cases) 1
• Third heart sound (S3) on right-sided examination 4
• Assess volume status, orthostatic blood pressure changes, and calculate BMI 3

Diagnostic Testing

Mandatory Initial Tests

The following tests are required in all patients: 2, 3

• 12-lead ECG: Look for right ventricular hypertrophy, right axis deviation, right bundle branch block, or evidence of prior MI 2, 3
• Chest radiograph (PA and lateral): Evaluate for cardiomegaly, pulmonary venous congestion, pleural effusions 2, 3
• Laboratory panel: Complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), BUN, creatinine, fasting glucose, lipid profile, liver function tests, thyroid-stimulating hormone 4, 2, 3

Natriuretic Peptides

• Obtain BNP or NT-proBNP when diagnosis is uncertain after initial evaluation 2, 3
• Elevated levels: BNP >35 pg/mL (ambulatory) or >100 pg/mL (hospitalized) support the diagnosis 6
• Normal levels make heart failure unlikely 3

Echocardiography: The Definitive Test

Two-dimensional echocardiography with Doppler is the single most useful diagnostic test and is mandatory during initial evaluation. 4, 2, 3

Three Fundamental Questions to Address:

1. Is left ventricular ejection fraction preserved or reduced? 4
2. Is left ventricular structure normal or abnormal? 4
3. Are there valvular, pericardial, or right ventricular abnormalities that could account for the presentation? 4

Specific Right Heart Assessment:

• Right ventricular size and systolic performance (quantitative assessment required) 4
• Tricuspid valve regurgitant gradient coupled with inferior vena cava dimension and respiratory variation to estimate pulmonary artery pressure and central venous pressure 4
• All valves evaluated for anatomic and flow abnormalities, particularly tricuspid and mitral regurgitation severity 4
• Right atrial size (quantitative measurement) 4

Additional Hemodynamic Parameters:

• E/E' ratio >15 strongly suggests elevated filling pressures 6
• Left atrial enlargement indicates chronic pressure elevation 6
• Short mitral deceleration time indicates elevated filling pressures 6
• Stroke volume determination via LV outflow tract measurement with pulsed Doppler 4

Diagnostic Criteria for Right Heart Failure

To establish the diagnosis, you must document: 1

1. Signs of elevated right atrial and venous pressures (elevated JVP, neck vein distension)
2. PLUS at least one of the following:
   • Compromised RV function on echocardiography
   • Pulmonary hypertension on echocardiography
   • Peripheral edema and congestive hepatomegaly

Common Pitfalls

• Do not rely solely on chest X-ray or ECG for determining the specific cardiac abnormality—they have low sensitivity and specificity 4
• A totally normal echocardiographic filling pattern argues against clinical heart failure, but isolated abnormalities can occur without heart failure 4
• Right heart failure patients are preload-dependent—volume status assessment is critical before initiating diuresis 5
• Early recognition and identifying the underlying etiology are crucial for effective treatment and improved prognosis 1