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Clinical Signs and Electrocardiography

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Right Heart Pathology

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Abstract

Right ventricular failure is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder that impairs the ability of the right ventricle to fill or to eject blood. The approach to the patient with known or suspected right heart pathology begins with a directed history and targeted physical examination, the scope of which depends on the clinical context at the time of presentation. These exams are augmented by a series of paraclinic tests that help to accurately establish etiology and classify severity. Symptoms of right heart disease are often due to the underlying disease and depend on the severity of the condition. In acute life threatening situations, i.e. acute pulmonary embolism or right ventricular myocardial infarction, the clinical presentation may be dominated by hemodynamic instability even progressing to cardiogenic shock. The clinical signs encountered in patients with chronic right heart pathology are initially due to the development of pulmonary hypertension; afterwards, they are completed by the development of right ventricular hypertrophy and a typical picture of right ventricular failure, dominated by systemic congestion.

The electrocardiogram is a standard part of the initial assessment of every patient with suspected right heart failure and also in previously diagnosed patients presented for a routine examination or for a new decompensation. Right ventricular hypertrophy, right axis deviation, and right bundle-branch block may suggest chronic right ventricular pressure overload. The sensitivity of the ECG for the diagnosis of pulmonary hypertension is poor, whereas the specificity of signs of right ventricular hypertrophy is high. Electrocardiographic changes do not correlate with disease severity or prognosis.

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References

  1. Weitzenblum E, Chaouat A. Cor pulmonale. Chron Respir Dis. 2009;6(3):177–85.

    Article  CAS  PubMed  Google Scholar 

  2. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance, and management of right ventricular failure. Circulation. 2008;117(13):1717–31.

    Article  PubMed  Google Scholar 

  3. Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev. 2008;4(1):49–59. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2774585&tool=pmcentrez&rendertype=abstract.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Watts JA, Marchick MR, Kline JA. Right ventricular heart failure from pulmonary embolism: key distinctions from chronic pulmonary hypertension. J Card Fail. 2010;16(3):250–9. https://doi.org/10.1016/j.cardfail.2009.11.008.

    Article  PubMed  Google Scholar 

  5. Dumitru I, Baker MM, Ooi HH. Heart failure clinical presentation. eMedicine; 2014 from: http://emedicine.medscape.com/article/163062-clinical.

  6. Mesquita SM, Castro CR, Ikari NM, Oliveira SA, Lopes AA. Likelihood of left main coronary artery compression based on pulmonary trunk diameter in patients with pulmonary hypertension. Am J Med. 2004;116:369.

    Article  PubMed  Google Scholar 

  7. Safi M, Eslami V, Shabestari AA, Saadat H, Namazi MH, Vakili H, et al. Extrinsic compression of left main coronary artery by the pulmonary trunk secondary to pulmonary hypertension documented using 64-slice multidetector computed tomography coronary angiography. Clin Cardiol. 2009;32(8):426.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Tongers J, et al. Incidence and clinical relevance of supraventricular tachyarrhythmias in pulmonary hypertension. Am Heart J. 2017;153(1):127–32. https://doi.org/10.1016/j.ahj.2006.09.008.

    Article  Google Scholar 

  9. Rajdev A, Garan H, Biviano A. Arrhythmias in pulmonary arterial hypertension. Prog Cardiovasc Dis. 2012;55(2):180–6. https://doi.org/10.1016/j.pcad. 2012.06.002. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832144/.

    Article  PubMed  Google Scholar 

  10. Arena V, De Giorgio F, Abbate A, Capelli A, De Mercurio D, Carbone A. Fatal pulmonary arterial dissection and sudden death as initial manifestation of primary pulmonary hypertension: a case report. Cardiovasc Pathol. 2004;13:230.

    Article  PubMed  Google Scholar 

  11. Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald’s heart disease: a textbook of cardiovascular medicine. 10th ed. Philadelphia: Saunders; 2014.

    Google Scholar 

  12. Rubin LJ, Hopkins W. Clinical features and diagnosis of pulmonary hypertension in adults. Uptodate Topic 8249 Version 22.0; 2017.

    Google Scholar 

  13. Tapson VF. Acute pulmonary embolism. Cardiol Clin. 2004;22:353.

    Article  PubMed  Google Scholar 

  14. Applefeld MM. The jugular venous pressure and pulse contour. In: Hurst JW, Walker HK, Hall WD, editors. Clinical methods: the history, physical, and laboratory examinations. Boston: Butterworths; 1990.

    Google Scholar 

  15. Shapira Y, Porter A, Wurzel M. Evaluation of tricuspid regurgitation severity: echocardiographic and clinical correlation. J Am Soc Echocardiogr. 1998;11(6):652.

    Article  CAS  PubMed  Google Scholar 

  16. Wiese J. The abdominojugular reflux sign. Am J Med. 2000;109(1):59.

    Article  CAS  PubMed  Google Scholar 

  17. Ambrosy AP, et al. The predictive value of transaminases at admission in patients hospitalized for heart failure: findings from the RO-AHFS registry. Eur Heart J Acute Cardiovasc Care. 2013;2(2):99–108. http://journals.sagepub.com/doi/10.1177/2048872612474906.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dorobantu M, Badila E. Insuficienta Cardiaca Cronica. In: Dorobantu M, editor. Compendiu de Boli Cardiovasculare. Bucharest: Editura Universitara Carol Davila; 2010.

    Google Scholar 

  19. Farber MO, et al. Hormonal abnormalities affecting sodium and water balance in acute respiratory failure due to chronic obstructive lung disease. Chest. 1984;85(1):49–54. https://doi.org/10.1378/chest.85.1.49.

    Article  PubMed  CAS  Google Scholar 

  20. Porcel JM. Pleural effusions from congestive heart failure. Semin Respir Crit Care Med. 2010;31(6):689.

    Article  PubMed  Google Scholar 

  21. Han CH, Choi JE, Chung JH. Clinical utility of pleural fluid NT-pro brain natriuretic peptide (NT-proBNP) in patients with pleural effusions. Intern Med. 2008;47(19):1669–74. https://www.jstage.jst.go.jp/article/internalmedicine/47/19/47_19_1669/_pdf.

    Article  PubMed  Google Scholar 

  22. Kopcinovic LM, Culej J. Pleural, peritoneal and pericardial effusions – a biochemical approach. Biochem Med. 2014;24(1):123–37. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3936968/.

    Article  CAS  Google Scholar 

  23. Natanzon A, Kronzon I. Pericardial and pleural effusions in congestive heart failure. Anatomical, pathophysiologic, and clinical considerations. Am J Med Sci. 2009;338(3):211–6. https://doi.org/10.1097/MAJ.0b013 e3181a3936f.

    Article  PubMed  Google Scholar 

  24. Otto CM. Etiology, clinical features, and evaluation of tricuspid regurgitation. UpToDate Topic 8119 Version 10.0; 2017.

    Google Scholar 

  25. Fukuda S, Gillinov AM, Song JM, Daimon M, Kongsaerepong V, Thomas JD, Shiota T. Echocardiographic insights into atrial and ventricular mechanisms of functional tricuspid regurgitation. Am Heart J. 2006;152:1208.

    Article  PubMed  Google Scholar 

  26. Chockalingam A, et al. Right ventricular myocardial infarction: presentation and acute outcomes. Angiology. 2005;56(4):371–6. https://doi.org/10.1177/000331970505600 402.

    Article  PubMed  Google Scholar 

  27. Silverman BD, Carabajal NR, Chorches MA, Taranto AI. Tricuspid regurgitation and acute myocardial infarction. Arch Intern Med. 1982;142(7):1394–5. https://doi.org/10.1001/archinte.1982.00340200164031.

    Article  PubMed  CAS  Google Scholar 

  28. van Lingen R, Warshow U, Dalton HR, Hussaini SH. Jaundice as a presentation of heart failure. J R Soc Med. 2005;98(8):357–9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1181835/.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Feldt RH, et al. Protein-losing enteropathy after the Fontan operation. J Thorac Cardiovasc Surg. 1996;112(3):672–80. https://doi.org/10.1016/S0022-5223(96)70051-X.

    Article  PubMed  CAS  Google Scholar 

  30. Ahearn GS, Tapson VF, Rebeiz A, Greenfield JC Jr. Electrocardiography to define clinical status in primary pulmonary hypertension and pulmonary arterial hypertension secondary to collagen vascular disease. Chest. 2002;122:524.

    Article  PubMed  Google Scholar 

  31. Bossone E, Paciocco G, Iarussi D, Agretto A, Iacono A, Gillespie BW, et al. The prognostic role of the ECG in primary pulmonary hypertension. Chest. 2002;121:513.

    Article  PubMed  Google Scholar 

  32. Oswald-Mammosser M, Oswald T, Nyankiye E, Dickele MC, Grange D, Weitzenblum E. Non-invasive diagnosis of pulmonary hypertension in chronic obstructive pulmonary disease. Comparison of ECG, radiological measurements, echocardiography and myocardial scintigraphy. Eur J Respir Dis. 1987;71:419.

    PubMed  CAS  Google Scholar 

  33. Surawicz B, Knilans T. Chou’s electrocardiography in clinical practice. 6th ed. Philadelphia: Saunders; 2008.

    Google Scholar 

  34. Hancock EW, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram. Part V: electrocardiogram changes associated with cardiac chamber hypertrophy a scientific statement from the american heart association electrocardiography. J Am Coll Cardiol. 2009;53(11):992–1002. https://doi.org/10.1016/j.jacc.2008.12.015.

    Article  PubMed  Google Scholar 

  35. Gross D. Contributions to the functional morphology of the P wave. Am Heart J. 1961;61:436.

    Article  CAS  PubMed  Google Scholar 

  36. Murphy ML, et al. Reevaluation of electrocardiographic criteria for left, right and combined cardiac ventricular hypertrophy. Am J Cardiol. 1984;53(8):1140–7. https://doi.org/10.1016/0002-9149(84)90651-9.

    Article  PubMed  CAS  Google Scholar 

  37. Goldberger AL. Myocardial infarction: electrocardiographic differential diagnosis. 4th ed. St. Louis: Mosby-Year Book; 1991.

    Google Scholar 

  38. Chia BL, Tan HC, Lim YT. Right sided chest lead electrocardiographic abnormalities in acute pulmonary embolism. Int J Cardiol. 1997;61:43.

    Article  CAS  PubMed  Google Scholar 

  39. Ferrari E, et al. The ECG in pulmonary embolism: predictive value of negative t waves in precordial leads - 80 case reports. Chest. 1997;111(3):537–43. https://doi.org/10.1378/chest.111.3.537.

    Article  PubMed  CAS  Google Scholar 

  40. Zehender M, et al. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med. 1993;328(14):981–8. https://doi.org/10.1056/NEJM199304083281401.

    Article  PubMed  CAS  Google Scholar 

  41. Nasir K, et al. Electrocardiographic features of arrhythmogenic right ventricular dysplasia/cardiomyopathy according to disease severity. Circulation. 2004;110(12):1527 LP–1534. http://circ.ahajournals.org/content/110/12/1527.abstract.

    Article  Google Scholar 

  42. Perez Diez D, Brugada J. Diagnosis and management of arrhythmogenic right ventricular dysplasia. Eur J Cardiol Pract. 2008;7(6)

    Google Scholar 

  43. Zhang L, Liu L, Kowey PR, Fontaine GH. The electrocardiographic manifestations of arrhythmogenic right ventricular dysplasia. Curr Cardiol Rev. 2014;10(3):237–45. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040875/.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Chu AF, Zado E, Marchlinski FE. Atrial arrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia and ventricular tachycardia. Am J Cardiol. 2010;106(5):720–2. https://doi.org/10.1016/j.amjcard.2010.04.031.

    Article  PubMed  Google Scholar 

  45. Incalzi RA, Fuso L, De Rosa M, Di Napoli A, Basso S, Pagliari G, Pistelli BT. Electrocardiographic signs of chronic cor pulmonale: a negative prognostic finding in chronic obstructive pulmonary disease. Circulation. 1999;99:1600–5. https://doi.org/10.1161/01.CIR.99.12.1600.

    Article  PubMed  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

    Elisabeta Bădilă

  2. Internal Medicine Department, Clinical Emergency Hospital Bucharest, Bucharest, Romania

    Elisabeta Bădilă

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  1. Elisabeta Bădilă
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Editors and Affiliations

  1. Department of Medicine, Titu Maiorescu University, Bucharest, Romania

    Silviu Ionel Dumitrescu

  2. Department of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

    Ion C. Ţintoiu

  3. Department of Surgery, Chinese University of Hong Kong, Sha Tin, Hong Kong

    Malcolm John Underwood

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Bădilă, E. (2018). Clinical Signs and Electrocardiography. In: Dumitrescu, S., Ţintoiu, I., Underwood, M. (eds) Right Heart Pathology. Springer, Cham. https://doi.org/10.1007/978-3-319-73764-5_30

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  • DOI: https://doi.org/10.1007/978-3-319-73764-5_30

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