Review Question - QID 107870

Left-sided heart failure may also result in right-sided failure; therefore, the presentation of left-sided heart failure may include ankle edema, abdominal fullness, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or persistent coughing. In contrast, right-sided heart failure would be less likely to manifest with basilar crackles on pulmonary exam.

Physical exam findings in left-sided heart failure may include bibasilar crackles, left-displaced PMI, S3 or S4 gallop. In contrast, right-sided failure may manifest with atrial fibrillation, jugular venous distention, hepatojugular reflux, hepatomegaly. A definitive diagnosis is achieved through echocardiogram findings interpreted in the context of the clinical presentation.

King et al. discuss the diagnosis and management of heart failure. Diastolic heart failure with preserved left ventricular function is the cause of heart failure in 40-50% of heart failure patients. When BNP levels are normal, systolic heart failure is an unlikely cause and diastolic failure is more likely. Evaluation for ischemic heart disease should be pursued in all patients with heart failure, as coronary artery disease is the most common etiology of heart failure.

Friedberg et al. review similarities, differences, and interactions between left ventricular failure versus right ventricular failure. The interventricular septum as well as shared myocardial fibers and shared pericardium between the left and right ventricles lead to many interactions between the two ventricles. This allows for contraction of the left ventricle to affect right ventricular pressure development and for right ventricular filling to affect left ventricular function.

Illustration A compares signs and symptoms seen in right-sided versus left-sided heart failure.

Incorrect Answers:
Answer 1: Left-sided heart failure is associated with a decreased ejection fraction, whereas right-sided heart failure manifests with an increased or normal ejection fraction on echocardiogram.
Answer 3: Hepatomegaly and/or hepatojugular reflux may be seen in right-sided heart failure as well as in left-sided failure that evolves into right-sided failure. Hepatojugular reflux occurs when firm pressure over the right upper quadrant of the abdomen elicits a sustained increase in jugular venous pressure.
Answers 4&5: Lower extremity edema and ankle swelling may occur in right-sided heart failure or in left-sided failure that causes right-sided heart failure.