Right heart failure overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Rim Halaby; Jad Z Al Danaf
Overview
The right ventricle was previously recognized as a simple conduit between the systemic and the pulmonary circulation until recently when its importance in maintaining hemodynamic stability and organ function has been recognized. In fact, right heart function acts as an important prognostic factor in congenital heart diseases, pulmonary hypertension and right heart failure. Right heart failure can be defined as failure of the right ventricle to pump blood into the lungs adequately. It consists of an intricate clinical syndrome resulting from several functional and structural cardiovascular disorders that alter right ventricular right ventricle filling and/or ejection capacity. Furthermore, it has been shown that isolated right ventricle failure, despite its rarity as compared to left ventricular left ventricle failure, carries a worse prognosis. Hence, right heart failure presents distinctive challenges in identification and management. Right heart failure is also used interchangeably with cor pulmonale when the pathology is caused by an underlying lung disease[1][2].
Classification
There are many different ways to categorize Right heart failure, including:
- Whether the abnormality is due to insufficient contraction (systolic dysfunction), or due to insufficient relaxation of the heart (diastolic dysfunction), or to both.
- Whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload).
- Whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure).
- The degree of functional impairment conferred by the abnormality (as reflected in the New York Heart Association Functional Classification[3])
- The degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/renal failure, etc.
Pathophysiology
The pathophysiological processes underlying right heart failure can be divided broadly into three: decreased right ventricular contractility, right ventricular pressure overload, right ventricular volume overload [4]. The right ventricle tries to adapt acutely by dilatation and chronically by hypertrophy. Whether dilatation or hypertrophy occur, right heart failure gets further exacerbated as a result of these adaptive mechanisms.
Causes
There are acute and chronic causes of right heart failure. Acute right heart failure is associated with right ventricular dilation. Chronic right heart failure is often associated with right ventricular hypertrophy.
Epidemiology and Demographics
The prevalence of heart failure has been increasing due to the increase in the aging population, the early detection, preventive measures and improvement in the therapy. The prevalence of heart failure in the United States was estimated in 2006 to be 5.8 million people of all ages with an estimated incidence of 10/1000 for individuals older than 65 years of age.[5]
Natural History, Complications and Prognosis
Diagnosis
In the initial approach to a patient with RHF, it is important to determine the underlying etiology, assess the functional status of the patient, determine the presence of any end organ damage (liver and kidney most notably), and any other associated conditions.
History and Symptoms
Physical Exam
Laboratory Findings
Electrocardiogram
Chest X-ray
Echocardiography
Treatment
Medical Therapy
Surgical Therapy
Future or Investigational Therapies
Medications:
References
- ↑ Haddad F, Hunt SA, Rosenthal DN, Murphy DJ. Right ventricular function in cardiovascular disease, part I: Anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation 2008;117:1436-48.
- ↑ .McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Mathier MA, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol. 2009;53:1573-619.
- ↑ Criteria Committee, New York Heart Association. Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis, 6th ed. Boston: Little, Brown and Co., 1964;114.
- ↑ Piazza G, Goldhaber SZ (2005). "The acutely decompensated right ventricle: pathways for diagnosis and management". Chest. 128 (3): 1836–52. doi:10.1378/chest.128.3.1836. PMID 16162794.
- ↑ WRITING GROUP MEMBERS. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S; et al. (2010). "Heart disease and stroke statistics--2010 update: a report from the American Heart Association". Circulation. 121 (7): e46–e215. doi:10.1161/CIRCULATIONAHA.109.192667. PMID 20019324.