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What is heart failure?

In heart failure, the heart has lost its ability to adequately pump blood out of the ventricle. Heart failure can be classified as right or left-sided, depending on which chamber of the heart is affected. In most cases, right-sided heart failure is a result of left-sided heart failure, though it can occur as a consequence of other conditions. Patients with right-sided heart failure (also called right ventricular failure) are not able to pump blood adequately into pulmonary circulation.

Causes of right-sided heart failure

As mentioned above, most cases of right-sided heart failure are due to left ventricular failure. However, there are several other pathophysiological processes that can lead to failure of the right ventricle. 

How left-sided heart failure causes right-sided heart failure

In left-sided heart failure, the left ventricle cannot adequately pump blood out into systemic circulation. As a result, this build up of blood causes pressure to increase in the pulmonary vasculature. When pressures inside the pulmonary vasculature are elevated, the right side of the heart must work harder to pump blood into the lungs. Over time, the right ventricle hypertrophies and dilates, leading to right ventricular heart failure.

Now that you’ve got some background information on right heart failure, let’s learn how to care for these patients using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

Patients with right-ventricular failure (RVF) can have the following signs and symptoms: 

  • Peripheral edema and/or abdominal fluid retention (ascites)
  • Jugular venous distension (JVD)
  • Shortness of breath, coughing
  • Sudden weight gain due to fluid retention
  • Dizziness and fatigue
  • Nausea, loss of appetite
  • Nocturnal polyuria
  • Hepatomegaly
How to assess for JVD in right heart failure patients.

A: How do you ASSESS a patient with right-sided heart failure?

One of the most important, and easiest, assessments for a patient with heart failure is to weigh them. Sudden increases in weight can signify a heart failure exacerbation, so it’s important to weigh the patient daily at the same time each day.

Other key assessments include obtaining a set of VS, monitoring the patient for edema, JVD, and shortness of breath. In addition, assess the abdomen for signs of fluid buildup and hepatomegaly (an enlarged liver). 

It’s also important to perform a full cardiovascular assessment, which may reveal:

  • Audible S3 or tricuspid murmur – remember that S3 is a key indicator of ventricular dysfunction
  • Right ventricular heave – this is a visible and palpable pulsation of the chest, located just to the left of the sternum
  • Paradoxical pulse (drop in blood pressure by more than 10 mmHg during inhalation)
  • Tachycardia
  • Hypotension
  • Cool extremities with delayed capillary refill
Not sure what to focus on when studying? Download the FREE LATTE method template

T: What TESTS are utilized to diagnose right-sided heart failure?

In addition to a thorough physical assessment, specific tests are utilized in the evaluation of a patient with right-sided heart failure. These include: 

Echocardiogram – An echocardiogram is an ultrasound of the heart. This test will show the right ventricle’s size, provide important data about its function, and estimate pulmonary artery pressure. This test can be conducted one of two ways. The least invasive is a transthoracic echocardiogram where the transducer is placed against the chest wall. The wand emits sound waves which create an image of the heart. More detailed images can be obtained from a transesophageal echocardiogram. In this test, the transducer is introduced into the esophagus, which is much closer to the heart. This test requires the use of sedation or anesthesia.

Chest X-ray – A standard chest x-ray can reveal an enlarged heart and pulmonary congestion.

EKG – A 12-lead electrocardiogram will show if the patient is also suffering from any cardiac arrhythmias as a result of the failing ventricle.

Blood tests – Common blood tests for a patient with right-sided heart failure include BNP (which will be elevated) and tests to evaluate hepatic and renal involvement.

MRI – Magnetic resonance imaging can be utilized to measure right ventricular function and volumes. 

MUGA scan – Multiple-gated acquisition scanning is a test that uses a radioactive substance to visualize the heart’s structure and function.

Right-sided heart catheterization – This invasive procedure provides a detailed look at the heart and involves the physician inserting a long, thin catheter through a major vessel such as the femoral vein. As this catheter is advanced through the heart, the cardiologist takes measurements from the right atrium and ventricle and is able to determine pulmonary artery pressure. A right-heart catheterization can also provide an indirect measurement of cardiac output.

T: How is right-sided heart failure TREATED?

In general, right-sided heart failure is treated by addressing the underlying problem. For example, if the right ventricular failure is due to pulmonary hypertension, medications that dilate the pulmonary vasculature can reduce the workload on the right side of the heart. Or, if the RVF is due to hypovolemia, providing fluids will help the right ventricle function more effectively. 

General treatments for right-sided heart failure include: 

  • Fluid restriction – In some cases, patients with heart failure will be advised not to take in more than 1.5 or 2 liters of fluid per day.
  • Sodium restriction – Since excess sodium leads to fluid retention, patients with heart failure should follow a low sodium diet of no more than 3 g sodium per day.
  • Diuretics – A diuretic such as furosemide may be utilized to rid the body of excess fluid in volume overloaded patients. Care must be taken in individuals with right heart failure since volume depletion can lead to hemodynamic compromise.
  • ACE-inhibitors or ARB (ex: valsartan) – These medications work by disrupting the RAAS pathway and have been shown to decrease the risk of hospitalizations in patients with heart failure. Note that ACEi and ARBs can cause hyperkalemia so they are used cautiously in patients with renal insufficiency.
  • Beta blockers (ex: metoprolol) – Beta blockers cause decreased blood pressure and heart rate and have been shown to reduce the incidence of cardiovascular mortality and hospitalizations in patients with heart failure.
  • Mineralocorticoid receptor antagonists such as spironolactone. These medications block the effects of aldosterone and can lead to hyperkalemia, so they are avoided in those with renal insufficiency and may be avoided in patients taking an ACE-inhibitor or ARB.
  • SGLT2 inhibitors – Though these drugs are primarily used to treat type 2 diabetes, studies show that they can reduce the risk of cardiovascular death and heart-failure related hospitalizations (ex: dapagliflozin)
  • Support oxygenation – Individuals with SpO2 < 90% should receive supplemental oxygen as needed.
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E: How do you educate the patient about right-sided heart failure?

Cardiac rehabilitation – Teach your patient that cardiac rehab can help slow the progression of the disease. It consists of medically supervised exercise programs and extensive heart-failure education.

Daily weights – A key way patients can monitor heart failure is with daily weighing. Teach your patient to weigh at the same time each day and that any sudden increase of 2 or more pounds in a day (or 5 pounds in a week) should be reported to their care team as soon as possible as this could be a sign of fluid retention.

Monitor blood pressure – Teach your patient how to measure their blood pressure at home, especially if they are taking a beta blocker, ACE-inhibitor, ARB, or diuretic.

Dietary changes – Individuals with right-sided heart failure should eat a heart-healthy diet that is low in fat and rich in whole grains, fruits and vegetables. They should also limit sodium intake, and avoid or limit alcohol and caffeine. 

Other lifestyle changes – Other proactive steps you can share with your patient are to get regular exercise, quit smoking, get consistent sleep at night, and manage stress through activities such as meditation or yoga.

Stay healthy – Patients with heart failure should get their recommended vaccines, including pneumonia, flu and COVID-19 vaccinations.

When to seek medical attention – Teach your patient to seek medical care if they develop worsening symptoms such as shortness of breath, increase in daily weight, increased edema, fatigue, dizziness, or nausea. They should also seek medical attention for any signs of respiratory infection, sustained tachycardia, chest pain, or any changes in their heart rhythm.

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References:

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Vallerand, A. H., & et al. (2024c). Metoprolol (Kapspargo Sprinkle, Lopressor). In Davis’s Drug Guide (19th ed.). F. A. Davis Company. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51497/all/metoprolol?refer=true

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Last Updated on December 12, 2024 by Maureen Osuna, MSN, RN