We heard about the smörgåsbord of cases that were seen the evening prior, including cases of:
- transient hypoxia of unclear etiology
- paraspinal absess
- management of cancer-related pain
- right-heart failure
I thought I was take a moment to review the diagnosis and management of right heart failure, which are gleaned from guidelines published by the Canadian Cardiovascular Society in 2009. You can find the full set of guidelines by clicking on this link.
Right heart failure (RHF) can be due to systolic and/or diastolic dysfunction, and can be an isolated occurrence, though it is more commonly associated with left heart failure.
To make the diagnosis, at least two features should be present:
1) Signs and symptoms consistent with RHF. These typically fall into three categories:
- Fluid retention (eg, ascites, peripheral edema, anasarca)
- Exercise intolerance and fatigue (eg, low cardiac output, diastolic and systolic dysfunction)
- Hypotension (especially with atrial and ventricular arrhythmias, and low cardiac output)
2) Objective evidence of abnormal right-sided cardiac structure or function or elevated intracardiac pressures
The etiology of RHF can often be broken down into the following categories:
- Increased afterload, including left-sided heart failure and pulmonary arterial hypertension
- Right ventricular (RV) myopathic process, RV infarction and restrictive heart disease
- Right-sided valvular heart disease (triscuspid and pulmonary)
- Congenital heart disease
- Pericardial disease (a mimic of RHF)
On physical examination, one may find one or more of the following:
- Elevated JVP (with CV waves possibly present with tricuspid regurgitation)
- Hepatomegaly (from passive hepatic regurgitation)
- Ascites
- Peripheral edema
- RV heave
- Palpable P2
- Systolic murmur at left lower sternal border consistent with tricuspid regurgiation
- Right-sided S3
The diagnosis is typically made using:
- Echocardiography
- Consider cardiac MRI and MUGA scan, as indicated
- If the diagnosis of pulmonary arterial hypertension is felt to be the cause, then right-heart catheterization should be considered, as it is the gold standard for the diagnosis of pulmonary hypertension.
In regards to management, generally, diuretics are the mainstay of therapy. However, diuretics should be given judiciously, as patient's LV filling pressures are often low, and overdiuresis may lead to intravascular volume contraction, precipitating hypotension, pre-renal acute kidney injury, etc.
Always be mindful of the patient's electrolyte status (in particular, their potassium and magnesium), as diuretics can lead to hypokalemia and hypomagnesemia - a recipe for arrythmias (and thus, further exacerbation of their heart failure).
