By Richard N. Fogoros, MD
Medically reviewed by Richard N. Fogoros, MD
Right-sided heart failure develops when the right side of the heart does not pump blood as well as it should be, causing blood to back up into the venous system and limiting how much blood the heart can pump per minute.1Symptoms of right-sided heart failure, such as dyspnea (shortness of breath), edema (swelling of the limbs), and fatigue can be severe. There are a multitude of reasons the right side of the heart might become weak and so treatment, which can include lifestyle changes and medication, is determined based on the cause.
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Anatomy of the Heart
The heart is made up of four chambers. The upper chambers are called the left and right atria, and the lower chambers are called the left and right ventricles. A wall of muscle called the septum separates the left and right atria and the left and right ventricles.
The job of the heart's left ventricle is to pump blood out of the heart to all organs of the body against relatively high pressure, requiring the walls of the left ventricle to be muscular, thick, and strong. By contrast, the right ventricle’s job is to pump “used,” oxygen-poor blood to the lungs via the pulmonary artery to be replenished with oxygen.1 It can work under low pressure, and is a relatively thin-walled structure, with much less cardiac muscle than the left ventricle.
Symptoms
The symptoms of right-sided heart failure aren't dissimilar to those of left-sided heart failure, but they can be more severe:
Shortness of breath (dyspnea), even after only a small amount of exertion
Weakness and lethargy
Fatigue
Swelling (edema), that often involves not only the ankles and lower extremities but also the thighs, abdomen, and chest
Swollen, painful liver
Severe ascites (fluid accumulation in the abdominal cavity)
Significant loss of appetite
Fainting (syncope) in response to exercise
Dizziness
Sudden weight gain
Increased urge to urinate
Swollen neck veins
Forgetfulness and confusion
Right-sided heart failure:
Often has more severe symptoms than left-sided heart failure
Can occur as a result of left-sided heart failure
If not caused by left-sided heart failure, is almost always due to some sort of lung disorder, which can include pulmonary hypertension, pulmonary embolism or chronic obstructive pulmonary disease (COPD)
Left-sided heart failure:
Can result from valvular heart disease
Can result from a heart attack
Can be caused by dilated cardiomyopathy
Can be caused by hypertrophic cardiomyopathy
Causes
The conditions that cause predominantly right-sided heart failure are different from those known to cause predominantly left-sided heart failure and fall into three categories.
Pulmonary Hypertension
Pulmonary hypertension is elevated blood pressure in the pulmonary artery.2 It can lead to right-sided heart failure because the walls of the right side of the heart are thin and relatively inefficient at pumping under conditions of high pressure. If the right ventricle has to work for extended periods of time against elevated pressures in the pulmonary artery, it begins to fail.
Pulmonary hypertension associated with right-sided heart failure can develop due to:
Left-sided heart failure: So called “typical” heart failure increases blood pressure within the pulmonary vascular system that can eventually affect the right side of the heart. In fact, it is correct to say that right-sided heart failure is a common and natural consequence of longstanding or poorly treated left-sided heart failure.2
Pulmonary embolus: A large pulmonary embolus can acutely elevate pulmonary artery pressure to very high levels. Smaller, recurrent pulmonary emboli can gradually increase pulmonary artery pressure, and thus may cause a more insidious onset of right heart failure.
Chronic lung disease: Chronic forms of lung disease, especially chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea can eventually produce pulmonary hypertension and right heart failure.3
Acute respiratory distress syndrome (ARDS): This condition can produce an acute form of pulmonary hypertension and right heart failure.4
Congenital heart disease: Atrial septal defect and ventricular septal defect in particular can eventually produce pulmonary hypertension and right heart failure.3
Other potential causes of pulmonary hypertension include primary pulmonary hypertension, scleroderma, sarcoidosis, or various forms of vasculitis affecting the lungs.3
Right-sided heart failure that is not caused by cardiac disease involving the left side of the heart is almost always due to a lung disorder that produces pulmonary hypertension. Right-sided heart failure that is secondary to a pulmonary condition is called cor pulmonale.
Valvular Heart Disease
Any type of valvular heart disease whose chief effect is to increase the pressure within the right side of the heart or to obstruct the flow of blood through the right side of the heart can produce right-sided heart failure.4
This might include:
Regurgitation (leaking) of the tricuspid and pulmonary valves because of pulmonary hypertension
Stenosis (narrowing) of the tricuspid or pulmonary valves due to congenital or rheumatic heart disease affecting other parts of the heart. (Tricuspid or pulmonary valve disease, by itself, is an infrequent cause of right-sided heart failure.)
Stenosis of the mitral valve—the valve that lies between the left atrium and left ventricle—which is a common cause of right-sided heart failure: Blood returning to the left atrium from the lungs tends to “dam up” when mitral stenosis is present, leading to increased vascular pressures in the lungs, which eventually produces pulmonary hypertension and right-sided heart failure.
Right Ventricular Myocardial Infarction
People who have a myocardial infarction (heart attack) caused by a blockage in the right coronary artery may suffer from damage to the right ventricular muscle, producing right-sided heart failure.1 Treating a right ventricular heart attack is similar to treating any myocardial infarction, including rapidly opening up the blocked blood vessel with “clot-busting” drugs or a stent.
However, because right-sided heart failure can limit the amount of blood that reaches the left side of the heart, drugs aimed mainly at treating left-sided ventricular weakness (such as nitrates, beta blockers, and calcium channel blockers) need to be used with great caution in people having right ventricular heart attacks.
Other conditions associated with right-sided heart failure include diabetes, HIV infection, thyroid problems, heart arrhythmias, and high blood pressure.5
Diagnosis
Diagnosis of right-sided heart failure typically requires a thorough physical examination by a cardiologist as well as medical history and any of a variety of tests. When reviewing health history, they will be especially suspicious of heart failure if you have had deep venous thrombosis or pulmonary embolus.
Tests used to diagnose right-sided heart failure include:
Electrocardiogram (ECG) and echocardiogram studies, which can reveal elevated pulmonary artery pressure and may also reveal valvular heart disease or disease affecting the cardiac muscle2
Pulmonary function testing to confirm the presence and severity of COPD
Blood tests to measure substances in the blood released in response to heart failure and to assess kidney, liver, and thyroid function
Sleep study to determine if apnea is a factor
Computerized tomography (CT) scans, which are 3-D X-rays of the heart
Magnetic Resonance Imaging (MRI) which use radio waves, magnets, and a computer to create detailed pictures of the heart6
Cardiac catheterization, in which a catheter is inserted into a chamber or vessel of the heart to diagnose blockages and defects
Coronary angiography, which involves injecting dye that can be seen on an X-ray into the heart chambers so the flow of blood through the heart can be visualized
Chest X-rays to determine whether the heart is enlarged and/or the lungs are congested
Cardiac stress testing, which assesses heart function during exercise under controlled conditions: Used along with an EKG, the test can show changes to the heart’s rate, rhythm, or electrical activity as well as blood pressure.
Treatment
Adequate treatment of right-sided heart failure relies on identifying and treating the underlying cause:
If the cause is valvular heart disease (most typically, mitral stenosis), surgical repair or replacement of the diseased valve is necessary.
When a right ventricular myocardial infarction is the cause, aggressive and rapid treatment to open the blocked right coronary artery is needed.
If the underlying cause is left-sided heart failure, treatment for that condition must be optimized.
When the cause is a pulmonary disorder (that is, if cor pulmonale is present), treatment for the underlying lung problem must be optimized.
While the underlying disease process is being identified, medications may be prescribed, including:
Judicious use of diuretics to relieve excessive edema
Drugs to reduce pulmonary artery pressure
A low-fat, low-cholesterol, low-sodium diet to help improve symptoms
Gentle aerobic exercise to help strengthen the heart
A ventricular assist device (VAD) implant to help a weak heart pump more efficiently6
Although a last resort, right-sided heart failure is sometimes treated with a heart transplant, in which the damaged heart is surgically removed and replaced with a healthy heart from a deceased donor.
Coping
If you've been diagnosed with heart failure, it's important to be proactive in the management of your condition. In some cases, medication adjustments and lifestyle changes may be enough to help address symptoms. :
Eat a healthy diet, heavy on fresh fruits, and vegetables7
Cut back on salt8
Maintain a healthy weight9
Increase your physical activity (with your healthcare provider's guidance if you're new to exercise)10
Quit smoking
Cut back on alcohol or quit drinking altogether
Maintain a strong social network
Reduce stress
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