What are the signs and symptoms of left‑sided and right‑sided heart failure?

Signs and Symptoms of Heart Failure: Left-Sided vs Right-Sided

Left-Sided Heart Failure

Left-sided heart failure primarily manifests with pulmonary congestion rather than peripheral fluid retention, causing dyspnea and orthopnea as the predominant symptoms. 1

Pulmonary Manifestations

• Dyspnea (shortness of breath) is the hallmark symptom, occurring due to elevated pulmonary venous pressure 1
• Orthopnea (difficulty breathing when lying flat) results from redistribution of fluid into the lungs 1
• Pulmonary rales (crackles on lung examination) indicate fluid accumulation in the alveoli 1
• Pleural effusions are common in acutely decompensated chronic heart failure 1
• Radiographic redistribution of pulmonary vasculature is one of the best findings for detecting increased filling pressure 2

Cardiac Examination Findings

• Abnormal apical impulse is one of the best findings for detecting systolic dysfunction 2
• S3 or S4 gallop may be present over the left ventricle 1
• Q waves or left bundle branch block on electrocardiogram suggest systolic dysfunction 2
• Radiographic cardiomegaly is a reliable indicator of systolic dysfunction 2

Key Clinical Distinction

• Peripheral edema is typically absent or minimal in isolated left heart failure 1
• Elevated blood pressure during heart failure is associated with diastolic dysfunction 2

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Right-Sided Heart Failure

Right-sided heart failure causes systemic venous congestion with prominent peripheral edema, hepatomegaly, and elevated jugular venous pressure, distinguishing it from left-sided failure by the anatomic location of fluid accumulation. 1

Venous Congestion Signs

• Elevated jugular venous pressure (JVP) is the most reliable clinical indicator for diagnosis and severity assessment 1, 3
  • Assess JVP with the patient at 45 degrees to accurately gauge right atrial pressure 1
• Peripheral edema (ankle swelling) progresses to extensive leg edema as the condition worsens 4
• Hepatomegaly (enlarged liver) from hepatic congestion causes early satiety and epigastric fullness/pain 1
• Ascites develops in advanced cases with generalized fluid accumulation 4

Cardiac Examination Findings

• RV heave (right ventricular lift) may be present but is often subtle 5, 1
• Loud P2 sound of pulmonary valve closure indicates pulmonary hypertension 1
• S3 or S4 gallop over the right ventricle 1
• Large V waves in the jugular venous pulse 1
• Holosystolic murmur of tricuspid regurgitation at the lower left sternal border that increases on inspiration 5

Systemic Manifestations

• Decreased exercise tolerance results from reduced cardiac output 1
• Fatigue and weakness reflect impaired tissue perfusion 1
• Cool extremities indicate reduced cardiac output and tissue hypoperfusion 1
• Oliguria (reduced urine output) occurs due to decreased renal perfusion 1

Advanced Manifestations

• Hypoxia and cyanosis, particularly peripheral cyanosis in severe cases 1
  • Central cyanosis may indicate right-to-left shunt through a patent foramen ovale or atrial septal defect 5, 1
• Confusion and altered mental status can occur with severe tissue hypoperfusion 1
• Cachexia from poor nutrient absorption and systemic inflammation 1
• Syncope can result from severely reduced cardiac output 1
• Angina may occur from RV ischemia in severe cases 1

Critical Distinguishing Feature

• Lung sounds are usually normal in isolated right heart failure, distinguishing it from left heart failure with pulmonary congestion 1
• Breathlessness without overt signs of pulmonary congestion distinguishes isolated right heart failure from left heart failure 1

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Important Clinical Pitfalls

Right-Left Mismatch

• Right-left filling pressure mismatch occurs in more than 1 in 4 patients with heart failure, meaning elevated JVP may not always correlate with elevated left-sided pressures 6
• When empiric therapy guided by JVP is not effective, additional hemodynamic measurement should be considered 6

Biventricular Failure

• Right-sided heart failure often coexists with left-sided heart failure, but can occur in isolation due to pulmonary hypertension, right ventricular infarction, or pulmonary embolism 1
• The key distinction is anatomic location: right heart failure causes backward congestion into the systemic circulation, while left heart failure causes backward congestion into the pulmonary circulation 1

Diagnostic Considerations

• A normal ECG does not exclude severe pulmonary hypertension, as sensitivity is only 55% 1
• A normal chest radiograph does not exclude mild pulmonary hypertension or left heart disease 1
• Jugular venous pressure may be normal even in the presence of severe tricuspid regurgitation because of the large and compliant right atrium 5