Primary right heart failure may occur as a result of acute or chronic
myocarditis in the context of rheumatic fever. Valve defects, shunts or
obstructions result in secondary right heart failure. Heart failure is not in
itself a disease, but the consequence of one or more diseases. Right heart
failure may precede the onset of a left heart failure.
The (massive) overload of the right ventricle is a consequence of:
• a volume overload, for example in the case of a congenital or acquired shunt
or in patients with tricuspidal insufficiency;
Rx thorax: right heart failure, increase in
volume of the right sections
• an overload of pressure, as in pulmonary embolism (acute pulmonary heart) or
in mitral or pulmonary stenosis;
Rx thorax in right heart failure, increase in volume of the right sections
• a mechanical decrease in contractility, for example in myocarditis, in
constrictive pericarditis or in amyloidosis;
• an increase in cardiac dynamics, such as in tachycardia or thyrotoxicosis.
It produces peripheral stasis when the right ventricle is unable to cope with
overload. In this case, the diastolic pressure of the right ventricle, the right
atrium pressure and capillary venous pressure increase. However, this retrograde
insufficiency also results in anterograde insufficiency: decreases the systolic
volume of the right ventricle (and consequently also the left one), the
pulmonary perfusion is compromised and the size of the atrium and of the left
ventricle is reduced. With the increase in size of the right ventricle and the
distension of the papillary muscle and of the tricuspid valve ring, a
tricuspidal insufficiency is generated (right holosystolic murmur); dilatation
of the right atrium can induce atrial fibrillation.
The jugular veins are clearly dilated, turgid and pulsatile; patients tend to develop peripheral varices and venous thrombosis. The liver has increased in size and is sore due to the distention of its capsule; in case of longer duration of the right cardiac insufficiency or in case of global heart failure, ascites can also be produced. Cyanosis and generalized edema will be detected in the sloping parts of the body. The edemas are better appreciable in the malleolus and feet the fovea induced by acupressure disappears very slowly (Q. In the patient bed you can also appreciate edema in the sacral region (anasarcato state) Overall, the edemas cause a considerable weight increase This is easily perceived by patients and they complain of sleep disorders due to polyuria (nocturia), and in case of left heart failure, generalized asthenia and lung syndromes will also be associated.
Diagnosis is based on medical history and physical examination. A marked
hypertrophy of the right cavities can be seen on the chest radiograph. The ECG
shows an ST-segment subdivision, mainly between V1 and V3. Using
echocardiography it is possible to highlight the valvulopathies, the movements
of the cardiac wall and measure the ejection fraction (FE). There may be
proteinuria upon examination of the urine.
Causal therapy, as long as it is possible, is a priority. Ventricular
contractility can be enhanced by ACE inhibitors, which reduce resistances, and /
or digital that has an inotropic action. Preload can improve with the use of
diuretics, nitrates or vasodilators; the afterload with vasodilators or
diuretics.
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