Right sided heart failure

[DrAwesomo]

How to determine the volume status for right sided heart failure if the patient does not have any significant pedal edema but still have SOB?

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[Raryn]

How to determine the volume status for right sided heart failure if the patient does not have any significant pedal edema but still have SOB?

Gold standard would probably be a swan/rhc.

Echo would help.

Fluid challenge if you want.

A good physical exam, +/- a CVP (probably useless).

Try weighing the patient and compare it to their baseline 😛

 

[VentJockey]

Give them lasix and measure how much they put out until their creatinine bumps. 😉

 

[VentJockey]

By the way, just in case someone isn't sure...I'm totally joking in the above post...

 

[bronx43]

Give them lasix and measure how much they put out until their creatinine bumps. 😉

Lol, sometimes this is the only way...

 

[jdh71]

By the way, just in case someone isn't sure...I'm totally joking in the above post...

It's not far from the truth though.

 

[jdh71]

How to determine the volume status for right sided heart failure if the patient does not have any significant pedal edema but still have SOB?

I would humbly suggest without signs of failure, your fluid status is fine enough. Look for other reasons for the dyspnea that are not RHF related.

 

[Instatewaiter]

How to determine the volume status for right sided heart failure if the patient does not have any significant pedal edema but still have SOB?

The exam, i hate to say it, is largely unhelpful in true, severe RV failure. In mild RV failure, can still be helpful. But once you need an RA pressure of 15 or so to fill the LV, your exam isnt helpful. What is are:

Swan
LVEDP
Mitral E/e' on echo

 

[jdh71]

The exam, i hate to say it, is largely unhelpful in true, severe RV failure. In mild RV failure, can still be helpful. But once you need an RA pressure of 15 or so to fill the LV, your exam isnt helpful. What is are:

Swan
LVEDP
Mitral E/e' on echo

Nonsense. RV failure will be present on exam unless super acute.

 

[Raryn]

Nonsense. RV failure will be present on exam unless super acute.

Not to argue with the pulmonologist about right heart disease, but I was always taught that not all heart failure is congestive. Heck, last expert I talked to was very insistent on how "congestive heart failure" is a misnomer for the majority of the patients, hence why the cardiologists just prefer "HF" these days. (HFrEF and HFpEF for the pedants) Went on to say that there's plenty of people where you might have cardiogenic dyspnea due to an inability to increase cardiac output, but be perfectly compensated at rest without signs/sx of congestion.

 

[ArkansasMed]

For right sided heart failure I have been personally using JVP to determine a rough fluid status. If you have trouble visualizing then push on the right upper quadrant gently and watch the jugular vein rise. I found for most patients that when the JVP reached NL limits they were essentially at their baseline.

 

[jdh71]

Not to argue with the pulmonologist about right heart disease, but I was always taught that not all heart failure is congestive. Heck, last expert I talked to was very insistent on how "congestive heart failure" is a misnomer for the majority of the patients, hence why the cardiologists just prefer "HF" these days. (HFrEF and HFpEF for the pedants) Went on to say that there's plenty of people where you might have cardiogenic dyspnea due to an inability to increase cardiac output, but be perfectly compensated at rest without signs/sx of congestion.

Cardiologist get pedantic. But this should surprise no one because we all know the people in our residencies who went into cardiology. Side issue.

Give any rule or generalization in medicine and we can all find an outlier and rule breaker. Also noted.

With all that said the right heart and left heart respond to load differently. It's nuanced but the LV can get away with a more varied amount of adaptions and it is correct that this doesn't necessarily require any "congestion". The problem is you can't apply this thinking in a general sense directly to the RV in exactly the same manner. The RV essentially responds to a load like it's a big extension of the venous system with dilation and lacks a lot of the LVs ability to just increase its contractile function and hypertrophy. And because of this, RV failure, at least in a chronic sense, should clearly give you exam findings. The kind of acute failure that wont show up as exam findings for the RV is the kind of failure kills you dead - which is the nature of the acutely failing RV and it's forward feeding cycle of crap. Don't pass go. Don't collect 200 dollars. The physician won't see pretibial edema.

 

[Instatewaiter]

Nonsense. RV failure will be present on exam unless super acute.

For right sided heart failure I have been personally using JVP to determine a rough fluid status. If you have trouble visualizing then push on the right upper quadrant gently and watch the jugular vein rise. I found for most patients that when the JVP reached NL limits they were essentially at their baseline.

For chronic LV failure, the JVP is useful. However, for chronic RV failure (or acute for that matter) it is not. The issue with JVP or edema in chronic RV failure is that it doesn't represent left sided filling pressures well. The worse the RV, the higher the right sided filling pressure needed to be to fill the LV. Thus a JVP of 10 or 12 cm may be euvolemic for RV failure and anything less will underfill the LV.

So, without knowledge of a surrogate for left sided filling pressures (thus a wedge from the swan, LVEDP on a cath or an E/e' on an echo) with correlation to the exam at that time, the exam is unhelpful.

 

[jdh71]

For chronic LV failure, the JVP is useful. However, for chronic RV failure (or acute for that matter) it is not. The issue with JVP or edema in chronic RV failure is that it doesn't represent left sided filling pressures well. The worse the RV, the higher the right sided filling pressure needed to be to fill the LV. Thus a JVP of 10 or 12 cm may be euvolemic for RV failure and anything less will underfill the LV.

So, without knowledge of a surrogate for left sided filling pressures (thus a wedge from the swan, LVEDP on a cath or an E/e' on an echo) with correlation to the exam at that time, the exam is unhelpful.

Patients with an *increase* in their edema even if they have it at baseline is a good metric for if their chronic RV failure has worsened.

 

[deleted547339]

This thread makes me happy I'm not an interest....this stuff makes my head spin.

But I'm glad there are people who really care about this.

 

[gutonc]

This thread makes me happy I'm not an interest....this stuff makes my head spin.

But I'm glad there are people who really care about this.

I'm an "interest" but don't give 2 sh**ts about this stuff either.

The heart is there to pump the chemo around. If it cant do it well enough, I'm out and it's someone else's problem.

 

[Instatewaiter]

Patients with an *increase* in their edema even if they have it at baseline is a good metric for if their chronic RV failure has worsened.

I'll concede that... but it could also be just worsening RV failure requiring higher filling pressures to fill the left side.

 

[ArkansasMed]

For chronic LV failure, the JVP is useful. However, for chronic RV failure (or acute for that matter) it is not. The issue with JVP or edema in chronic RV failure is that it doesn't represent left sided filling pressures well. The worse the RV, the higher the right sided filling pressure needed to be to fill the LV. Thus a JVP of 10 or 12 cm may be euvolemic for RV failure and anything less will underfill the LV.

So, without knowledge of a surrogate for left sided filling pressures (thus a wedge from the swan, LVEDP on a cath or an E/e' on an echo) with correlation to the exam at that time, the exam is unhelpful.

I do not mean to be a pain about this but I do think JVP in general is probably one of your best assessments of right sided heart failure excluding echo/invasive exams. You are right, usually it shows the effects of left heart failure that lead to right heart failure, but JVP is suppose to show you when the right heart is failing, regardless the cause. This article is a good review of JVP from the Cleveland Clinic. It makes a few good points and taught me a few things I did not know.
http://www.ccjm.org/uploads/media/media_04e5176_638.pdf

 

[Instatewaiter]

I do not mean to be a pain about this but I do think JVP in general is probably one of your best assessments of right sided heart failure excluding echo/invasive exams. You are right, usually it shows the effects of left heart failure that lead to right heart failure, but JVP is suppose to show you when the right heart is failing, regardless the cause. This article is a good review of JVP from the Cleveland Clinic. It makes a few good points and taught me a few things I did not know.
http://www.ccjm.org/uploads/media/media_04e5176_638.pdf

Realize I am a cardiology fellow perhaps at said institution. I have some experience with this

 

[Instatewaiter]

I do not mean to be a pain about this but I do think JVP in general is probably one of your best assessments of right sided heart failure excluding echo/invasive exams. You are right, usually it shows the effects of left heart failure that lead to right heart failure, but JVP is suppose to show you when the right heart is failing, regardless the cause. This article is a good review of JVP from the Cleveland Clinic. It makes a few good points and taught me a few things I did not know.
http://www.ccjm.org/uploads/media/media_04e5176_638.pdf

The issue is not if there is right sided failure. The issue is where euvolemic is. For chronic RV failure, a JVP of 6 is not euvolemic, it is underfilled. A JVP of 10 cm may not be hypervolemic but rather hypovolemic...

Those people with a JVP of 10 or 12(ie an RAP of 8 or 9 on RHC) will have edema because of the hydrostatic pressure but won't be filling the LV adequately. I realize you aren't going to get the intracacies of this but just trust that I am right.

 

[ArkansasMed]

The issue is not if there is right sided failure. The issue is where euvolemic is. For chronic RV failure, a JVP of 6 is not euvolemic, it is underfilled. A JVP of 10 cm may not be hypervolemic but rather hypovolemic...

Those people with a JVP of 10 or 12(ie an RAP of 8 or 9 on RHC) will have edema because of the hydrostatic pressure but won't be filling the LV adequately. I realize you aren't going to get the intracacies of this but just trust that I am right.

Fair enough. For my own knowledge then, if I am admitting a patient to the floors at 1am that has the said description from the original post of SOB, no peripheral edema and trying to access if there are right heart failure, how do I make my argument in the morning that they do or do not have right sided involvement and need diuresis without using JVP? This excludes cases like those with inferior MIs who are preload dependent.

 

[Instatewaiter]

Fair enough. For my own knowledge then, if I am admitting a patient to the floors at 1am that has the said description from the original post of SOB, no peripheral edema and trying to access if there are right heart failure, how do I make my argument in the morning that they do or do not have right sided involvement and need diuresis without using JVP? This excludes cases like those with inferior MIs who are preload dependent.

I am talking about primary right heart failure, not right heart failure from left sided failure. These adanced right heart failure patients are going to have right heart caths in the past, more than likely. Easy answer is look for their last right heart cath and see what the right sided filling pressure was relative to the left sided filling pressure (ie RAP vs PCWP). The 3/4 of the RAP in mmHg will give you the JVP in cm H2O. Compare to physical exam.

With regard to advanced left sided cardiomyopathy, it is exceptionally common for them to have enough lymphatics taht their CXR is clear. They often have no peripheral edema. So as you said, in this circumstance JVP is your best tool. Quite frankly, it is an underutilized part of the exam.

 

[NontradICUdoc]

In light of not having a right sided cath, either because the procedure was done somewhere else or before the system went to EMR, or any other reason, the estimated pressures from the ultrasound should at least give you some semblance of the function of the RV. Regarding the edema, there are so many other factors that can cause edema that can confound the exam. Most commonly would be chronic venous insufficiency, anasarca, etc. If there is especially concern for right heart failure, a bedside swan would be the way to go.