Right-Sided Heart Failure: Symptoms, Causes, Treatment

What is right-sided heart failure?

Right-sided heart failure refers to the condition where the right side of the heart is unable to properly pump blood to the lungs to receive oxygen. The right ventricle of the heart is responsible for pumping deoxygenated blood from the body’s veins into the lungs so it can become re-oxygenated. In right-sided heart failure, the right ventricle becomes enlarged and weakened over time, making it difficult to perform this important pumping function effectively. As a result, blood backs up in the veins returning to the heart from the body. This leads to fluid buildup in the legs, ankles and abdominal cavity.

Right-sided heart failure usually occurs secondary to other conditions that place extra strain on the right ventricle over time. Some common causes of right-sided heart failure include pulmonary hypertension, lung disease, congenital heart defects, left-sided heart failure, blood clots in the lungs and coronary artery disease. In pulmonary hypertension, the pressure in the pulmonary arteries and right side of the heart increases, forcing the right ventricle to work harder to overcome this resistance. Repeated damage to the pulmonary system from lung diseases like chronic obstructive pulmonary disease (COPD) or pulmonary fibrosis can also contribute to right-sided heart failure.

How common is right-sided heart failure?

Right-sided heart failure is less common than left-sided heart failure, which involves the left ventricle and side of the heart. Exact statistics on the prevalence of right-sided heart failure are difficult to determine, as it usually presents secondary to other cardiac or pulmonary conditions. Some estimates suggest right-sided heart failure accounts for approximately 10-30% of all heart failure cases.

The main causes of right-sided heart failure help provide insight into how common it may be. Pulmonary hypertension is a leading cause and has an estimated prevalence of 100 cases per million people. Other conditions like COPD and interstitial lung disease that often lead to pulmonary hypertension affect millions worldwide as well. Congenital heart defects are also a significant contributor, occurring in around 1 in 100 live births. As longevity increases globally and more people live with chronic lung and heart conditions, the incidence of right-sided heart failure is expected to rise steadily in the coming decades.

What causes right-sided heart failure?

As mentioned, right-sided heart failure generally occurs as a result of other underlying cardiac or pulmonary pathologies that place increased pressure and workload on the right ventricle over an extended period. Some of the most common specific causes include:

• Pulmonary hypertension – High blood pressure in the arteries of the lungs damages and constricts these vessels over time. The right ventricle then must work harder to overcome this resistance with each contraction.
• Left-sided heart failure – When the left ventricle fails, it backs up blood into the lungs, increasing pulmonary pressures and straining the right side of the heart.
• Lung disease – Conditions like COPD, pulmonary fibrosis and lung cancer can destroy lung tissue and stiffen the pulmonary arteries, raising pulmonary pressures.
• Pulmonary embolism – A blood clot blocking a pulmonary artery markedly increases resistance that segment of the lung. Multiple emboli damage the pulmonary system.
• Congenital heart disease – Defects like atrial or ventricular septal defects, which allow blood to shunt between the left and right sides of the heart before birth, cause chronic volume overload of the right ventricle.
• Coronary artery disease – A heart attack damaging the right ventricle’s muscle or restricting its blood supply can lead to right-sided heart failure.
• Valvular heart disease – Issues like tricuspid regurgitation allow backflow of blood into the right atrium, overworking the pumping chamber.

Signs and symptoms of right sided heart failure

The signs and symptoms of right-sided heart failure differ from left-sided failure due to the anatomic structures involved. Some signs and symptoms of right sided heart failure may be present include:

• Leg swelling (edema) – Fluid backs up in the legs and ankles as the failing right ventricle cannot effectively return blood from the lower body veins to the lungs.
• Abdominal swelling (ascites) – Fluid accumulation in the abdominal cavity is also common as venous blood pools in the liver and other organs.
• Liver enlargement (hepatomegaly) – Backed up blood causes hepatic congestion, increasing liver size.
• Jugular vein distension – The neck veins appear prominent and swollen with fluid due to increased right atrial pressure.
• Fatigue and weakness – Fluid overload taxes the cardiovascular system, causing low energy.
• Difficulty breathing (dyspnea) – Raised pressures in pulmonary arteries impair gas exchange and oxygenation in the lungs.
• Chest pain – Results from overworked muscles of the right ventricle or coronary insufficiency limiting its blood supply.
• Loss of appetite and unintentional weight loss – Fluid retention contrasts with wasting as cardiac output declines.
• Irregular heartbeats (arrhythmias) – The stressed, enlarged right ventricle is arrhythmogenic.

How is right-sided heart failure diagnosed?

Evaluating a patient’s medical history, performing a physical exam and ordering diagnostic tests are important for diagnosing right-sided heart failure:

• Medical history – Details risk factors, presenting symptoms and other relevant illnesses are obtained.
• Physical exam – Findings suggestive of right heart strain include elevated jugular venous pressure, an irregular heartbeat, leg swelling and liver enlargement on palpation.
• Chest x-ray – May show enlarged central pulmonary arteries, fluid buildup in the lung fissures or around the lungs.
• Electrocardiogram (EKG) – Can detect changes from an enlarged right atrium or ventricle, such as right axis deviation.
• Echocardiogram – Ultrasound of the heart provides a direct view of right ventricular size and function, as well as estimation of pulmonary pressures.
• Cardiac MRI or CT – Help evaluate the anatomy and function of all heart chambers, especially the right ventricle.
• Right heart catheterization – Gold standard invasive test to measure pulmonary artery pressures and assess the degree of pulmonary hypertension if present.
• Blood tests – Elevated levels of cardiac biomarkers like BNP indicate heart injury or strain on the right ventricle.

With testing to evaluate both cardiac structure/function and pulmonary hemodynamics, right-sided heart failure is distinguished from alternative conditions and the underlying etiology identified.

How is right-sided heart failure treated?

Treatment aims to relieve symptoms, improve heart function, reduce stress on the right ventricle and address the underlying cause if possible:

• Diuretics – “Water pills” like furosemide are first-line to reduce fluid overload from edema and ascites.
• Afterload reduction – Medications like calcium channel blockers, ACE inhibitors and ARBs lower pulmonary artery pressures if pulmonary hypertension is a factor.
• Digoxin – Provides positive inotropic support to enhance a weak right ventricle’s contractions.
• Antiarrhythmics – Drugs like amiodarone prevent dangerous arrhythmias from an enlarged right heart.
• Anticoagulation – With atrial fibrillation or history of blood clots, warfarin thins the blood and lowers embolic risk.
• Oxygen therapy – For lung disease associated hypoxemia, supplemental O2 raises oxygen levels.
• Lung volume reduction – Surgery may help emphysematous lung segments in COPD patients.
• Pulmonary thromboendarterectomy – Surgical option to remove chronic clots in major pulmonary arteries.
• Heart transplant – Rarely performed but considered for refractory cases unresponsive to other therapies.
• Managing underlying conditions – Treating pulmonary hypertension, heart defects or other causes is also important.

Overall treatment strategy and prognosis depends on severity of right heart dysfunction and potential for reversing underlying pathology.

How can I prevent right-sided heart failure?

While right-sided heart failure often develops secondary to other conditions, there are steps you can take to help reduce your risk:

• Manage underlying illnesses strictly. Proper treatment of high blood pressure, lung diseases like COPD, and other cardiac problems can help prevent further damage to the heart.
• Quit smoking and limit exposure to lung irritants. Smoking is a major risk factor for COPD and lung cancer, both of which can lead to pulmonary hypertension.
• Maintain a healthy weight. Carrying excess pounds strains the cardiovascular system and increases risks of heart disease and diabetes.
• Engage in regular physical activity. Exercise strengthens the heart muscle and improves lung function. Aim for at least 150 minutes per week of moderate activity.
• Follow a heart-healthy diet. Eat plenty of fruits and vegetables, lean proteins and whole grains. Limit sodium, unhealthy fats, sugars and processed foods.
• Manage blood sugar and cholesterol levels if prediabetic or hyperlipidemic. Diabetes and high cholesterol increase heart disease risks over time.
• Get recommended vaccinations. Flu shots and pneumococcal vaccines help prevent lung infections that injure pulmonary tissues.
• Ask your doctor about screening tests. Discuss any family history risks and whether earlier monitoring of pulmonary pressures or cardiac function is advised.
• Seek prompt medical care if you develop new symptoms. Don’t ignore early signs like leg swelling, breathlessness or chest pain that may signal developing heart issues.

Making lifestyle changes to support overall heart and lung health is important for reducing the chance of right-sided heart failure down the line.