Chronic Right Heart Failure: Pathogenesis, Haemodynamic Foundations, and a Pragmatic Diagnostic Algorithm

Area of Science:

• Cardiology
• Internal Medicine
• Physiology

Background:

• Chronic right heart failure (RHF) is underrecognized and poorly defined in clinical guidelines.
• Current definitions often relegate RHF to a secondary complication of left-sided heart disease.
• Conventional right ventricular (RV) systolic indices may not fully capture the RHF syndrome due to RV's unique physiology.

Purpose of the Study:

• To clarify the distinct pathophysiological and hemodynamic foundations of chronic RHF.
• To propose a pragmatic diagnostic algorithm for chronic RHF.
• To reframe the diagnosis of RHF around systemic venous hypertension rather than isolated RV metrics.

Main Methods:

• Review of pathophysiological and hemodynamic principles of chronic RHF.
• Proposal of a diagnostic algorithm based on elevated right atrial/central venous pressures.
• Inclusion of four minor criteria: systemic congestion, RV systolic dysfunction, pulmonary hypertension, or impaired RV-pulmonary arterial coupling.

Main Results:

• Chronic RHF is fundamentally characterized by the heart's inability to decongest the systemic venous circulation.
• Backward failure, not isolated RV systolic dysfunction, drives systemic and multi-organ congestion.
• A diagnostic algorithm requires elevated right atrial/central venous pressures plus at least one minor criterion.

Conclusions:

• The proposed framework centers RHF diagnosis on systemic venous hypertension, reflecting backward failure.
• This approach offers a coherent and readily applicable tool for diagnosing chronic RHF in clinical practice.
• The algorithm aims to bridge existing diagnostic gaps for this complex syndrome.