Clinical significance of pulmonary hypertension in interstitial lung disease: A consensus statement from the Pulmonary Vascular Research Institute's innovative drug development initiative—Group 3 pulmonary hypertension
What's The Difference Between Left- And Right-Sided Heart Failure?
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Heart failure occurs when the heart can't pump blood as well as it should. It can affect either the left side of the heart (left-sided heart failure) or the right side (right-sided heart failure). Heart failure can cause a variety of symptoms depending on which side is affected.
In left-sided heart failure, the left side of the heart cannot efficiently pump blood to the body. This can lead to a backup of blood in the lungs and symptoms like coughing and tiredness.
Right-sided heart failure happens when the right side of the heart can't adequately pump blood to the lungs to pick up oxygen. This can cause blood to back up in the veins and cause symptoms like swelling and nausea.
Left-sided heart failure usually occurs first. Right-sided heart failure is typically a result of left-sided heart failure. Both affect the heart's ability to circulate blood to vital organs throughout the body.
Depending on whether heart failure affects the heart's left or right side, symptoms can be a bit different. You might experience the following symptoms with left- or right-sided heart failure: Symptoms of Left-Sided Heart Failure Symptoms of Right-Sided Heart Failure Difficulty breathing or catching your breath Nausea Cough Loss of appetite Fatigue, extreme tiredness despite good rest Stomach pain Weakness Swelling in the lower legs, stomach, and neck veins Bluish lips and fingers Increased urination Problems concentrating Unexplained weight gain Difficulty sleeping while lying flat The main difference is that left- and right-sided heart failure occur in their respective sides of the heart. Each type has different underlying causes, and one is more common than the other. Their Causes The most common causes of left-sided heart failure are coronary artery disease (restricted blood flow to your heart due to plaque buildup in your coronary arteries) and hypertension (high blood pressure). Other risk factors of left-sided heart failure include: Diabetes Smoking Obesity Cardiomyopathy (disease of the heart muscle) An inactive lifestyle Right-sided heart failure is often caused by left-sided heart failure. As the left ventricle (lower chamber) weakens, pressure in the heart rises and causes fluid to back up into the lungs. This fluid eventually moves into the right side of the heart. Other conditions that can lead to right-sided heart failure include: Pneumonia Pulmonary embolism (a blood clot that travels to the lungs) Acute respiratory distress syndrome Pulmonary hypertension (high pressure in the lungs) Chronic obstructive pulmonary disease (COPD) or other lung diseases Number of Subtypes Left-sided heart failure has two main types: systolic failure and diastolic failure. In systolic heart failure, the heart's left lower chamber doesn't contract well, which reduces its force for pumping blood. Diastolic heart failure happens when the left ventricle becomes too stiff to fill with blood properly during rest. Right-sided heart failure isn't broken down into any specific types. Prevalence Left-sided heart failure is more common than right-sided heart failure. Estimates suggest that over half of people with heart failure have left-sided heart failure. Both left- and right-sided heart failure can cause problems for other organs. Fluid Retention Causes Symptoms When the heart doesn't pump enough blood, fluid builds up in the body, causing symptoms like swelling, weight gain, and shortness of breath. Drinking lots of liquids and consuming too much sodium can add to fluid retention. Some people with either type of heart failure may need to take medications such as diuretics to remove the excess fluid. They may also need to weigh themselves regularly and check their pulse and blood pressure. Strain on Organs Left- and right-sided heart failure can strain the heart and other organs, potentially even leading to liver or kidney damage. Reduced blood flow to the kidneys may impair their function and result in fluid buildup and elevated waste levels in the body. Heart failure can also cause congestion in the liver, which can lead to scarring and reduced function over time. Other possible complications from either type of heart failure include arrhythmias (irregular heartbeats), heart valve disease, and, in severe cases, sudden cardiac arrest. Treatment Options Medications, lifestyle changes, and implantable cardiac devices are common treatments to reduce symptoms and improve function for either type of heart failure. Lifestyle changes may include maintaining an optimal weight, avoiding or quitting smoking, managing stress, getting enough rest, adjusting fluid and salt intake, and avoiding alcohol. Medications vary by the type and class of heart failure you have but may include drugs to manage blood pressure and fluid retention. Devices and procedures are usually reserved for people with heart failure who don't respond to lifestyle changes and medications. In such cases, devices like implantable cardioverter defibrillators (ICDs) may help monitor heart rhythm and treat dangerous heartbeats. It's possible to have both left- and right-sided heart failure. When both sides of the heart are affected, it is called biventricular heart failure. This condition causes symptoms similar to each type of heart failure, including shortness of breath and fluid buildup. With both sides of the heart compromised, biventricular heart failure can lead to more severe limitations in daily activities and may require a combination of treatments. If you notice any symptoms of heart failure, contact your primary healthcare provider so they can diagnose or rule out heart failure. If you already have a heart failure diagnosis, let your cardiologist (heart specialist) or other healthcare provider know about any sudden worsening of symptoms. Symptoms to watch for include: Quick weight gain Shortness of breath, especially at rest Increased swelling in legs or ankles Stomach pain or swelling Difficulty sleeping Persistent dry cough Difficulty concentrating Nausea and loss of appetite loss Heart palpitations Mood changes, such as sadness or depression Left-sided and right-sided heart failure are two conditions that affect the way the heart pumps blood. Left-sided heart failure causes blood to back up in the lungs, often leading to symptoms like shortness of breath and coughing. Right-sided heart failure causes blood to back up in the veins, leading to swelling in the legs, ankles, and abdomen. Left-sided heart failure is more common and may lead to right-sided failure. Treatment options for either condition include lifestyle changes, medications, and implantable devices to help manage symptoms and improve heart function.Thanks for your feedback!
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Left Ventricular Assist Device Therapy And Right Heart Failure
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Chronic Heart Failure - Heart Failure With Preserved Ejection Fraction Topic Review
IntroductionChronic heart failure occurs when either the left ventricle, the right ventricle, or both require elevated filling pressures to maintain cardiac output. Heart failure is a syndrome, not a specific disease, and occurs as a final common pathway in multiple disease states.
Heart failure (HF) can be due to the following:
The section presents a review of diastolic congestive heart failure, commonly called HFpEF. Reviews of systolic congestive HF, or HFrEF, valvular heart disease, pulmonary hypertension and right HF, and high output HF are discussed elsewhere.
Pathophysiology –HFpEFLeft ventricular diastolic dysfunction is manifest when increased filling pressure (ie, left atrial, pulmonary capillary wedge and pulmonary artery diastolic pressures) is required in order to maintain cardiac output. HFpEF connotes diastolic dysfunction despite a normal ejection fraction. Diastolic dysfunction also occurs frequently in patients with HFrEF. [Hurst's The Heart Section 11:13a,14a-b,15a]
Although the renin-angiotensin-aldosterone system is activated in HFpEF, it is not as prominent as with systolic HF, and cardiac remodelling is less marked.
The figure below shows a schematic of the negative neurohormonal feedback mechanisms that become active in worsening HF:
Etiology –HFpEFSome of the underlying causes of HFpEF are listed below:
Hypertension may cause left ventricular hypertrophy (LVH) and impaired relaxation. Over time, this condition progresses, resulting in higher degrees of diastolic dysfunction, low cardiac output and symptoms of congestive HF.
Restrictive cardiomyopathies frequently involve myocardial infiltration — amyloid deposition, for instance. This results in diastolic relaxation abnormalities and, eventually, the syndrome of HFpEF.
Obstruction to LV outflow leads to left ventricular hypertrophy and diastolic dysfunction. Sustained tachycardia, such as unrecognized and uncontrolled atrial fibrillation with a rapid ventricular response, may occasionally result in HFpEF symptoms. However, more commonly, tachycardia-induced cardiomyopathy results in reduced ejection fraction.
The aging process of the heart is not well understood, but fibrotic changes in the myocardium typically occur with advanced age. This results in relaxation abnormalities that are often present by the age of 60. This can progress in the elderly, causing significant diastolic impairment and HFpEF.
Symptoms –HFpEFThe symptoms of HF include fatigue, exercise intolerance, dyspnea and eventually edema. The symptoms are similar regardless of the etiology of the heart disease, and reflect either impaired cardiac output or fluid retention. Symptoms are important in differentiating left ventricular failure from right ventricular failure.
Early in the course of left ventricular failure, the compensated right heart generates elevated pulmonary artery and wedge pressures that may result in dyspnea, pulmonary congestion or pulmonary edema.
As HF progresses, chronic elevation of pulmonary pressures lead to the development of right ventricular failure. The negative feedback mechanisms outline above result in fluid retention and systemic venous congestion.
Right HF symptoms include lower extremity-dependent edema. When the legs are elevated at night, reabsorption of extracellular fluid increases right heart preload, the fluid redistributes centrally and may cause pulmonary congestion with orthopnea (dyspnea while laying flat) or paroxysmal nocturnal dyspnea (PND). Systemic venous congestion may also lead to hepatic congestion with right upper quadrant abdominal pain.
Symptoms related to low cardiac output include fatigue, exercise intolerance and weakness. In extreme cases, cardiac cachexia can occur.
Clinical Classification –HFpEFTwo HF classification systems are widely used: the New York Heart Association (NYHA) functional classification and the American College of Cardiology and American Heart Association (ACC/AHA) staging system. [Heidenreich 2022;10a(e905)]
The NYHA system categorizes patients into one of four classes based on a health care professional's subjective assessment of the patient's symptoms:
Class I: No symptoms of HFClass II: Symptoms of HF with moderate exertion, such as walking two blocks or climbing two flights of stairsClass III: Symptoms of HF with minimal exertion such as walking one block or one flight of stairs, but no symptoms at restClass IV: Symptoms of HF at rest
The ACC/AHA staging categorizes patients into one of four stages on the basis of risk factors, cardiac structural abnormalities associated with HF and the presence of symptoms of HF: [Heidenreich 2022:10a]
Stage A: At high risk for HF but without symptoms, structural heart disease or cardiac biomarkers of stretch or injuryStage B: Pre-HF, defined as no signs or symptoms of HF but evidence of one of the following: structural heart disease, evidence of increased filling pressures or risk factors plus increased levels of BNPs or persistently elevated cardiac troponinStage C: Structural heart disease with prior or current symptoms of HFStage D: Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy (GDMT)
In addition to focusing on different classificatory parameters, the NYHA functional classification differs from the ACC/AHA heart failure staging in that NYHA allows movement from any one class to another while the ACC/AHA system only allows unidirectional progression of stages (A→B→C→D). [Heidenreich 2022:10a]
Diagnosis –HFpEFIn general, diagnosis of HF is initially based on clinical findings on history and physical examination. However, in recent years, 2D and Doppler echocardiography has become the standard laboratory method to confirm the clinical diagnosis and assess cardiac structure and function. [Metra 2017:3d]
There are four grades of echocardiographic diastolic dysfunction, as described below. Clinical manifestations of congestive HF may occur once grade II diastolic dysfunction is present, but not in the presence of grade I diastolic dysfunction (impaired relaxation).
Grade I (impaired relaxation): The E-wave velocity is reduced, resulting in E/A reversal (ratio < 1). The left atrial pressures are normal. The deceleration time of the E wave is prolonged, measuring greater than 200 milliseconds. The e/e' ratio measured by tissue Doppler is normal.
Grade II (pseudonormal): This is pathological finding characterized by elevated left atrial pressures. The E/A ratio is normal (0.8-1.5), and the deceleration time is normal (160-200 ms), but the e/e' ratio is elevated. The E/A ratio will be less than 1 with Valsalva. A major clue to the presence of grade II diastolic dysfunction vs. Normal diastolic function is the presence of structural heart disease such as left atrial enlargement, left ventricular hypertrophy or systolic dysfunction. If significant structural heart disease is present, and the E/A ratio as well as the deceleration time appear normal, suspect a pseudonormal pattern. Valsalva distinguishes pseudonormal from normal as well as the e/e' ratio. Diuresis can frequently reduce the left atrial pressure, relieving symptoms of HF and returning the hemodynamics to those of grade I diastolic dysfunction.
Grade III (reversible restrictive): This pathological finding is characterized by significantly elevated left atrial pressures. Also known as a "restrictive filling pattern," the E/A ratio is greater than 2, the deceleration time is less than 160 ms and the e/e' ratio is elevated. The E/A ratio changes to less than 1 with Valsalva. Diuresis can frequently reduce the left atrial pressure, relieving symptoms of HF and returning the hemodynamics to those of grade I diastolic dysfunction.
Grade IV (fixed restrictive): This finding is characterized by severely elevated left atrial pressures and indicates a poor prognosis. The E/A ratio is greater than 2, the deceleration time is low and the e/e' ratio is elevated. The major difference distinguishing grade III from grade IV diastolic dysfunction is the lack of E/A reversal with the Valsalva maneuver (no effect will be seen with Valsalva). Diuresis will not have a major effect on the left atrial pressures, and clinical HF is likely established. Grade IV diastolic dysfunction is present only in very advanced HF and frequently seen in end-stage restrictive cardiomyopathies such as amyloid cardiomyopathy.
Treatment –HFpEFUntil recently, prospective randomized controlled interventional trials in HFpEF populations did not a firm evidence base for therapy, and therapy was thus aimed at symptom relief and management of comorbidities. However, recent trials showed effectiveness of several agents in the HFpEF population, and based on those, the 2022 ACC/AHA/Heart Failure Society of America guideline for the management of HF makes several recommendations: [Heidenreich 2022:55b]
The guideline states that routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life is ineffective.
The guideline also states that patients with HFpEF and hypertension should have antihypertensive medications titrated to attain guideline-recommended blood pressure targets (Class I, level of evidence C) and that management of atrial fibrillation can be useful to improve symptoms in patients with HFpEF (Class IIa, level of evidence C).
As in patients with HFrEF, in patients with HFpEF, diuretics are recommended to reduce congestion and improve symptoms (Class I, level of evidence B). [Heidenreich 2022:56a]
References:
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