DE Novo R-CHF

Q: Patients with de novo right-sided congestive Heart Failure (CHF) may often have more severe symptoms than those with Left-sided CHF.

A) True

B) False

Answer: A

Unfortunately, R-CHF is usually underdiagnosed and less appreciated, although the symptoms may be more severe than L-CHF. It may go untreated for a longer period. To make things complicated, many of these patients may have an antecedent history of known L-CHF.

De novo R-CHF should be suspected in patients with valve pathologies, pulmonary hypertension, or congenital heart disease. One of the reasons these patients stay undiagnosed as symptoms appear to be more of abdominal or pulmonary diseases due to underlying ascites or dyspnea. Symptoms can be non-specific, such as easy fatigability, orthopnea, paroxysmal nocturnal dyspnea, chest discomfort, abdominal distention, anorexia, early satiety, and decreased exercise capacity. These symptoms are due to elevation in intracardiac pressures that reduce coronary perfusion pressure, hepatosplanchnic congestion, and gut edema.

Clinically, they may have jugular venous distention. The examiner should look for a prominent V wave. Kussmaul sign may be noticeable in advanced disease. Lower extremity edema is common. Another interesting feature is cachexia. Patients may have lesser muscle mass but stable or even increased body weight. This is due to fluid retention. Abdominal distention, positive fluid wave, and hepatomegaly should be looked for. Right Ventricular heave may be present with a loud P2 sound (caused by pulmonary hypertension). A murmur of tricuspid regurgitation (generally a holosystolic murmur over the left lower sternal border) may be present. 

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References:

1. Konstam MA, Kiernan MS, Bernstein D, et al. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e578.

2. Gorter TM, van Veldhuisen DJ, Bauersachs J, et al. Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018; 20:16.