What is the recommended management for right‑sided heart failure, including volume control, diuretics, treatment of underlying causes, and advanced therapies?

Management of Right-Sided Heart Failure

Loop diuretics are the first-line therapy for right heart failure with volume overload, combined with aggressive treatment of the underlying cause—most commonly left-sided heart disease, pulmonary hypertension, or acute pulmonary embolism. 1, 2

Initial Assessment and Diagnosis

Identify the underlying etiology immediately, as this determines the entire treatment strategy:

• Left-sided heart disease is the most common cause in clinical practice—evaluate LV systolic/diastolic function and valvular pathology with echocardiography first 3
• Pulmonary hypertension from any cause (chronic thromboembolic disease, interstitial lung disease, pulmonary arterial hypertension) is the second major pathway 3
• Acute causes requiring emergent intervention: massive pulmonary embolism (25-30% mortality) and RV infarction (25-30% mortality when complicating inferior MI) 2
• Structural causes: tricuspid regurgitation, pulmonic stenosis, congenital shunts (ASD, VSD), or infiltrative cardiomyopathies 3

Key physical examination findings to assess severity:

• Elevated jugular venous pressure at 45 degrees (most reliable indicator) 2
• Peripheral edema, hepatomegaly, ascites 2
• Kussmaul sign (paradoxical JVP rise with inspiration) indicates severe RV overload 2
• Cool extremities and oliguria reflect low cardiac output 2
• Critical pitfall: Lung sounds are typically clear in isolated right heart failure—pulmonary rales suggest left-sided involvement 2

Volume Management

Diuretics are the cornerstone of symptomatic treatment for systemic congestion:

• Loop diuretics (furosemide, bumetanide, torsemide) are first-line therapy 1, 2
• Add spironolactone (aldosterone antagonist) for enhanced diuresis, particularly with hepatic congestion and secondary hyperaldosteronism 1, 2
• Target: Complete elimination of elevated JVP and peripheral edema, even if mild hypotension or azotemia develops 2
• Monitor daily weights: Aim for 0.5-1.0 kg daily weight loss during active diuresis 2
• Sodium restriction to 2-3 grams daily enhances diuretic effectiveness 2

For refractory edema, use combination therapy with loop diuretics, thiazides, and aldosterone antagonists 2

Critical caveat: In acute RV infarction or massive pulmonary embolism presenting with hypotension and clear lungs, avoid diuretics entirely—these patients require cautious fluid administration (≤500 mL over 15-30 minutes) only if central venous pressure is low on IVC ultrasound 4. Aggressive volume depletion precipitates hemodynamic collapse 2, 4.

Treatment of Underlying Causes

Acute Right Ventricular Infarction

• Early revascularization of the right coronary artery is the definitive treatment 1
• Fluid loading (not diuretics) and inotropic support are the supportive measures 1
• Avoid nitrates and diuretics which worsen preload-dependent RV output 2

Pulmonary Embolism

• Anticoagulation is mandatory 1, 4
• Thrombolysis for massive PE with hemodynamic instability 1
• Surgical thrombectomy if thrombolysis fails or is contraindicated 1

Pulmonary Hypertension

• Calcium channel blockers (only in acute vasoreactivity responders), nitric oxide, or prostaglandins to reduce pulmonary vascular resistance 1, 4
• Sildenafil (20 mg three times daily PO) reduces pulmonary vascular resistance in RV failure with pulmonary hypertension 4
• Inhaled nitric oxide (5-40 ppm) provides selective pulmonary vasodilation without systemic hypotension—monitor methemoglobin every 6 hours and avoid abrupt discontinuation 4
• Epoprostenol (continuous IV prostacyclin) is the only therapy proven to prolong survival in pulmonary arterial hypertension and is preferred for critically ill patients 1

Valvular Disease

• Tricuspid valve surgery is recommended for severe TR undergoing left-sided valve surgery—do not defer, as reoperation carries 10-25% mortality 1
• Tricuspid valve repair with prosthetic ring is first-line over replacement 1
• Consider TV repair even for mild TR with annular dilation (>40 mm or >21 mm/m²) during left-sided surgery 1
• Acute severe aortic or mitral regurgitation from endocarditis requires early surgical intervention after antibiotic initiation 1
• Prosthetic valve thrombosis: Surgery is preferred for left-sided PVT; thrombolysis for right-sided PVT or high surgical risk 1

Hypertensive Crisis with Pulmonary Edema

• Immediate IV antihypertensive agents to reduce LV preload and afterload 1
• Oxygen therapy, CPAP, or non-invasive ventilation before intubation 1

Advanced Therapies and Hemodynamic Support

For hypotension with RV failure:

• Norepinephrine (0.05-3.3 mcg/kg/min) is the vasopressor of choice—improves systemic hemodynamics and coronary perfusion without increasing pulmonary vascular resistance 4
• Maintain systemic arterial pressure close to RV systolic pressure to preserve RV coronary perfusion 5

Inotropic support for refractory low cardiac output:

• Dobutamine may be used short-term for end-stage right heart failure 2
• Digoxin may be considered for refractory cases, though evidence is limited 1, 2

Oxygen therapy:

• Maintain oxygen saturation >90% in all hypoxemic patients 2, 4
• Hypoxemia worsens pulmonary vascular resistance and RV afterload 6

Mechanical circulatory support:

• Right ventricular assist devices (RVAD) for medically refractory right heart failure 7, 6
• Extracorporeal membrane oxygenation (ECMO) when medical management fails 5, 6
• Early consultation with pulmonary hypertension specialists and transfer to tertiary centers with mechanical support capabilities 6

Long-Term Management

For chronic right heart failure secondary to left-sided disease:

• Optimize RAAS inhibition and beta-blockade for reduced LV function 1
• Guideline-directed medical therapy for HFrEF is first-line treatment 1

For pulmonary arterial hypertension:

• Warfarin anticoagulation is recommended in all IPAH patients without contraindication 1
• Endothelin receptor antagonists (bosentan, ambrisentan) improve exercise capacity—monitor liver function monthly indefinitely 1
• Phosphodiesterase-5 inhibitors (sildenafil, tadalafil) improve exercise capacity 1

Critical Pitfalls to Avoid

• Do not aggressively fluid resuscitate hypotensive RV failure—this over-distends the RV, shifts the septum leftward, impairs LV filling, and worsens cardiac output 4
• Discontinue non-dihydropyridine calcium channel blockers (diltiazem, verapamil) immediately—these worsen hemodynamics and outcomes in heart failure 4
• Avoid intubation if possible in pulmonary hypertension—positive pressure ventilation reduces venous return and worsens RV output 6
• Never abruptly stop pulmonary vasodilators in patients on chronic therapy—this precipitates acute RV failure and death 6
• Do not assume normal lung sounds exclude heart failure—isolated right heart failure presents without pulmonary congestion 2