Right-Sided Heart Failure: Causes, Symptoms, Diagnosis, and Treatment

Oxygenated blood is delivered from the lungs to the left side of the heart, which in turn pumps that blood to the rest of the body. However, the right ventricle plays a crucial role in blood oxygenation, as it is responsible for directing deoxygenated blood toward the lungs.

Right heart failure (RHF) occurs when the right ventricle is unable to perform this function effectively. The most common cause of right heart failure is left ventricular failure (LVF), which increases pressure in the pulmonary vasculature and leads to pressure or volume overload in the right ventricle.

What are the causes of RHF?

Other than LVF, acute lung conditions that create pressure overload in the right heart can lead to RVF, including the following:

• Pneumonia
• Acute pulmonary embolism
• Mechanical ventilation
• Acute respiratory distress syndrome (ARDS)

Other chronic pressure overload conditions that contribute to RVF include:

• Primary pulmonary arterial hypertension (PAH)
• Secondary pulmonary hypertension

Congenital heart disease includes pulmonic stenosis, right ventricular outflow tract obstruction, the Ebstein anomaly, tetralogy of Fallot, transposition of great arteries, and hypoplastic left heart.

RVF due to volume overload can be due to the following conditions:

• Right-sided (tricuspid or pulmonary) valvular insufficiency
• Congenital defects with shunts, such as atrial septal defect and anomalous pulmonary venous return

The Following spectrum of disorders causing intrinsic right ventricular myocardial disease, hence, leading to RVF are:

• Right ventricular ischemia or infarction
• Infiltrative diseases such as amyloidosis or sarcoidosis
• Arrhythmogenic right ventricular dysplasia
• Genetic cardiomyopathies
• Microvascular disease 

Impaired ventricular filling may also result in RVF seen in the following conditions:

• Constrictive pericarditis
• Tricuspid stenosis
• Systemic vasodilatory shock
• Cardiac tamponade
• Superior vena cava syndrome
• Hypovolemia [1]

How common is RHF? 

More than 6 million Americans have heart failure. Each year, more than 900,000 people receive a heart failure diagnosis. 

Heart failure becomes increasingly common with advanced age. Studies have shown that around 2% of the population younger than 54 years old has heart failure. The number increases to around 8% for people over 75. 

What are the symptoms of RHF? 

Fluid build-up or swelling (oedema) in the feet, ankles, legs, lower back, abdomen, and liver (ascites) is the main sign of RHF. Other symptoms may include:

• Breathlessness
• Chest pain and discomfort
• Heart palpitations 

Fluid build-up in the liver or stomach may lead to

• Nausea
• Bloating
• Loss of appetite 

How is RHF diagnosed?

The following investigations can help diagnose RHF:

• Chest X-ray
• Electrocardiogram
• Blood tests, especially to measure natriuretic peptides
• Measuring ejection fraction

Echocardiogram

Further tests can also be used to confirm the diagnosis of RHF, or rule out other diagnosis:

• Cardiac MRI
• Cardiac CT
• Cardiac catheterization
• Stress test
• Nuclear exercise stress test 
• In rare cases, myocardial biopsy [2]

What is the conservative treatment for RHF? 

Treatment often includes lifestyle changes and medicines. Secondary heart failure is treated by addressing the primary condition causing it. Medications to help treat RHF include:

• Medicines relax blood vessels to lower blood pressure, improve blood flow, and decrease the strain on the heart, including:
  • Angiotensin-converting enzyme (ACE) inhibitors – e.g., enalapril (Vasotec, Epaned), lisinopril (Zestril, Qbrelis), and captopril.
  • Angiotensin II receptor blockers (ARB) – e.g., losartan (Cozaar), valsartan (Diovan), and candesartan (Atacand).
  • Angiotensin receptor plus neprilysin inhibitors (ARNIs) – e.g., sacubitril-valsartan (Entresto).
• Medicines slow the heart rate and lower blood pressure, also known as beta-blockers – e.g. carvedilol (Coreg), metoprolol (Lopressor, Toprol-XL, Kapspargo Sprinkle), and bisoprolol.
• Diuretics help prevent fluid buildup in your body and make you urinate more frequently. E.g., furosemide (Lasix, Furoscix). 

Potassium-sparing diuretics or aldosterone antagonists include spironolactone (Aldactone, CaroSpir) and eplerenone (Inspra). Unlike some other diuretics, these medicines can raise the level of potassium in the blood to dangerous levels. Talk with your healthcare professional about your diet and potassium intake.

• Medicine to lower blood sugar is often prescribed with diet and exercise to treat type 2 diabetes. For e.g., canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance).

Digoxin, also known as digitalis, helps the heart squeeze better to pump blood. It also tends to slow the heartbeat. 

What are the surgical options to treat heart failure? 

• Coronary artery bypass graft surgery: Healthy blood vessels from the leg, arm, or chest are grafted in place of severely blocked arteries, causing heart failure.
• Heart valve replacement in case of failure, damage, or malfunction.
• An Implantable cardioverter- defibrillator is a device similar to a pacemaker used to prevent complications of heart failure. The ICD checks the heartbeat. If the heart starts beating at a dangerous rhythm, the ICD tries to correct the beat. If the heart stops, the device shocks it back into regular rhythm. An ICD can also work as a pacemaker and speed up a slow heartbeat.
• Cardiac resynchronization therapy (CRT): It is also known as biventricular pacing, and is used for people whose lower heart chambers aren't pumping in sync with each other. Signals from the device tell the chambers to squeeze in a more coordinated way. 
• Ventricular assist device, also called a mechanical circulatory support device, helps pump blood from the lower chambers of the heart to the rest of the body. 
• Heart transplant: This option is for those with severe heart failure where neither medicines nor other surgical procedures will help. These people may need to have their hearts replaced with a healthy donor heart. [3] 

Lifestyle modifications such as quitting cigarettes, limiting alcohol, managing stress, regularly exercising, and regularizing sleep are almost always required for treatment success. In addition, home remedies such as cooking healthy meals, weight management, checking swelling in the extremities every day, adequate hydration, and eating plenty of fruits and vegetables add up to the treatment benefits. 

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