AHA: Right-Sided Heart Failure Evaluation, Management Guidelines

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The AHA offers recommendations on mechanical circulatory support and transplantation in right-sided HF.
The AHA offers recommendations on mechanical circulatory support and transplantation in right-sided HF.

In a new scientific statement published in Circulation, the American Heart Association (AHA) provides an in-depth overview of right-sided heart failure (RHF), including evaluation strategies and recent evidence-based management approaches.

To develop the scientific statement, the writing committee of the AHA analyzed recent RHF evaluation and treatment data from systematic literature reviews, translational and clinical studies, clinical practice guidelines, and expert opinion/statements. The investigators provide an overview of the epidemiology and pathogenesis of RHF, including acute and chronic RHF, HF with reduced ejection fraction (EF), HF with preserved EF, myocarditis, right ventricular myocardial infarction, and pressure-volume disease.

The writing committee offered recommendations regarding the physical examination of RHF, including using observable factors such as diaphoresis, tachypnea, and cyanosis. Serum markers were also discussed for the identification of RHF. For example, normal or minimally elevated transaminases may indicate chronic RHF, whereas high transaminase levels may be suggestive of acute RHF. The investigators did not, however, recommend elevated brain natriuretic peptide (BNP) as a reliable marker for determining the level of ventricle dysfunction in RHF. Despite this advice, BNP may still be used for determining prognosis in patients with RHF who also have pulmonary arterial hypertension.

Cardiac magnetic resonance imaging, which is the gold standard for assessment of right ventricular volume, mass, and EF in congenital heart disease, as well as radionuclide imaging are also recommended for evaluation of RHF. For evaluating hemodynamics of right ventricular (RV) function, the investigators suggested 6 calculations: right atrial pressure, right-to-left discordance of filling pressures, pulmonary artery pulsatility index, RV stroke work index, pulmonary vascular resistance, and pulmonary artery compliance.

In addition, the scientific statement offered updated guidelines on management strategies (eg, diuretics, renal replacement therapies, vasoactive therapies, and vasodilators), as well as guidelines on mechanical circulatory support and transplantation in patients with RHF. For the latter, the writing group suggested refraining from mechanical circulatory support unless the patient is refractory to optimal medical management.

According to the AHA, “Early identification is critical to improve care targeting this complex syndrome, which remains frequently misjudged given the diverse pathways and pathological processes leading to its condition.”

Reference

Konstam MA, Kiernan MS, Bernstein D, et al; for the American Heart Association Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; and Council on Cardiovascular Surgery and Anesthesia. Evaluation and management of right-sided heart failure: a scientific statement from the American Heart Association. Circulation. 2018;137(20):e578-e622.

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