From snapshot to trajectory: A multimodality right-heart monitoring framework across the heart failure spectrum

Right ventricular (RV) dysfunction, pulmonary vascular load, tricuspid regurgitation, and venous congestion are important determinants of symptoms and outcomes across the heart failure spectrum, yet longitudinal follow-up remains predominantly left ventricle-centered. This narrative review summarizes the physiological and multimodality imaging basis for serial right-heart assessment across HFrEF, HFmrEF, and HFpEF, using SGLT2 inhibition and dapagliflozin as a contemporary mechanistic example rather than the basis for a drug-specific monitoring algorithm. We propose a pragmatic, therapy-agnostic trajectory framework integrating clinical status, biomarkers, echocardiography, cardiac magnetic resonance, and selective invasive hemodynamics. The approach distinguishes RV dysfunction from overt right-heart failure, incorporates loading conditions, rhythm and tricuspid regurgitation phenotype, and prioritizes serial direction of change over isolated measurements. Emerging SGLT2 inhibitor data provide signals of favorable hemodynamic and RV-pulmonary arterial interaction in selected populations, although dedicated RV-focused randomized evidence remains limited. Suggested reassessment windows are illustrative rather than validated and should be individualized. This framework is intended to complement conventional heart failure assessment and support selective advanced imaging or hemodynamic clarification when clinical and right-heart trajectories are discordant.