Right heart failure

Definition: Right sided heart faliure is characterized by reduction in effective right ventricular output for any given right atrial pressure.

Causes:

1.       Secondary to LVF.

2.       Corpulmonale:

a)       Chronic bronchitis.

b)       Emphysema.

c)       Diffuse interstitial lung fibrosis.

3.       Valvular heart disease:

a)       Mitral stenosis (MS).

b)       Tricuspid stenosis and incompetence.

c)       Pulmonary stenosis and incompetence.

4.       Congenital heart disease: ASD, VSD, Fallot’s tetralogy.

5.       Pulmonary embolism.

6.       Myocarditis.

7.       Isolated right ventricular cardiomyopathy.

8.       Myocardial infraction and anaemia.

Clinical features:

Symptoms:

In early stage: (vague symptoms like)

·         Weakness, fatigue.

·         Loss of appetite.

·         Anorexia, nausea, vomiting.

In frank case:

1.       Pulmonary symtoms (if secondary to LHF or corpulmonale):

·         Breathlessness.

·         Cough with expectoraiton of forthy sputum.

2.       Gastrointestinal symptoms:

·         Right upper abdominal discomfort.

·         Ascites.

3.       Cerebral symtoms (due to cerebral congestion):

·         Insomnia.

·         Lack of concentration.

·         Drowsiness.

4.       Urinary symtoms: Oliguria (in day) and Polyuria (at night).

5.       Swelling of body: At first dependent part of the body like ankle, over sacrum then become generalised.

Signs:

1.       Patient may be dyspnoeic, propped-up position.

2.       Pulse: Low volume.

3.       Raised JVP: Positive hepatojugular reflux.

4.       Tender hepatomegaly.

5.       Ascites.

6.       Dependent pitting oedema (over ankle, sacrum).

7.       Evidence of LVF, MS.

8.      Signs of right ventricular or Biventricular cardiomegaly.

Investigations:

[A]Routine:

1.       X-ray chest P/A view: RVH or biventricular hypertrophy according to the cause.

2.       ECG:

·         Right ventricular hypertrophy (RVH).

·         Right axis deviation.

·         Strain pattern.

3.       Cardiac enzyme in acute heart failure to diagnose MI.

4.       CBC, liver biochemistry, blood urea and electrolytes.

[B]Specific:      

1.       Echocardiography.

2.       Cardiac catheterisation (for mesuarement of pessure with in right atrium, ventricle, their size and to quantify stenosis).

3.       Angiogram (during cardiac catheterisaiton-if done), show if there is any aneurysm and cardiomyopathy.

Differential diagnosis:

[A]Nephrotic syndrome:

·         Generalised oedema (first appear in face).

·         Puffiness of face with baggy eyelids.

·         Massive albuminuria.

·         Hypoalbuminaemia.

·         Hypercholesterolaemia.

·         Hepatosplenomegaly usually absent.

[B]Cirrhosis of liver:

·         Oedema due to hepatic cause usually starts with ascitis.

·         Firm hepatomegaly.

·         Palpable spleen in portal hypertension.

·         Jaundice.

·         H/O hepatitis or hepatotoxic drugs, alcholo.

 [C]Pericardial effusion:

·         Dyspnoea and cough.

·         Definite paradoxic pluse.

·         Area of cardiac dullness enlarged.

·         Apex beat is not palpable.

·         H/O causes, e.g uraemia, TB (may be) Present.

Complications:

1.       Uraemia due to diuretic therapy, Low cardiac output.

2.       Hypokalaemia due to diuretic therapy, hyperaldosteronism.

3.       Hyponatraemia due to diuretic therapy, inappropriate water retention, failure of the cell membrane ion pump.

4.       Impaired liver function due to hepatic venous congestion.

5.       Thromboembolism:

·         Deep vein thrombosis and pulmoanry embolism due to low cardiac output (COP) and immobility.

·         Systemic embolism due to AF or intracardiac thrombus in mitral stenosis (MS) or LV aneurysm.

6.      Arrhythmia: Atrial arrhythmia, ventricular arrhythmia.

Management:

[A]General measure:

1.       Bed rest in propped up position (for few days, if bed rest is prolonged, it leads to deep vein thrombosis)

2.       Dietary modifications:

a)       Avoid large meal.

b)       Weight reduction (if necessary)

c)       Salt restricted diet.

d)       Oxygen inhalation (6-8 liter/min)

[B]Drug therapy: (Drugs used are: Diuretics, vasodilators, digitalis and anti-arrhythmic agents)

1.       Tab. Frusemide (40 mg) 1-2 tab, once or twice daily.

2.        Supplement: Syrup KCL two TSF thrice daily.

3.       Vasodilator: esp. ACE-I.

4.       Digitalisation:

a)       If there is SVT/AF.

b)       If diuretic fails to control the heart failure.(Does of the drug depends on patients condition)

5.       Treatment of underlying causes.

Advice on release:

1.       Salt restricted diet.

2.       Avoid weight gain.

3.       Avoid heavy exercise/physical work.

4.       Frusemide (20-40 mg) twice weekly with  supplement.

5.       Digitalis: 1 tab daily, maintaince dose for life long (if used)

6.       Antibiotic (if sputum yellow/excessive)

7.       Visit to physician every 2 month interval.

Reference:

1.      Davidson’s Principle and practice of Medicine, 21^st edition.

2.      Kumar and Clark, clinical Medicine, 7^th edition.