Right heart strain

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Electrocardiogram of a person with pulmonary embolism, showing sinus tachycardia of approximately 100 beats per minute, large S wave in Lead I, moderate Q wave in Lead III, inverted T wave in Lead III, and inverted T waves in leads V1 and V3. Pulm embolism.jpg
Electrocardiogram of a person with pulmonary embolism, showing sinus tachycardia of approximately 100 beats per minute, large S wave in Lead I, moderate Q wave in Lead III, inverted T wave in Lead III, and inverted T waves in leads V1 and V3.

Right heart strain (also right ventricular strain or RV strain) is a medical finding of right ventricular dysfunction [1] where the heart muscle of the right ventricle (RV) is deformed. [2] Right heart strain can be caused by pulmonary hypertension, [3] pulmonary embolism (or PE, which itself can cause pulmonary hypertension [4] ), RV infarction (a heart attack affecting the RV), chronic lung disease (such as pulmonary fibrosis), pulmonic stenosis, [5] bronchospasm, and pneumothorax. [6]

Contents

When using an echocardiograph (echo) to visualize the heart, [lower-alpha 1] strain can appear with the RV being enlarged and more round than typical. When normal, the RV is about half the size of the left ventricle (LV). When strained, it can be as large as or larger than the LV. [5] An important potential finding with echo is McConnell's sign, where only the RV apex wall contracts; [7] it is specific for right heart strain and typically indicates a large PE. [8]

On an electrocardiogram (ECG), there are multiple ways RV strain can be demonstrated. A finding of S1Q3T3 [lower-alpha 2] is an insensitive [10] sign of right heart strain. [11] It is non-specific (as it does not indicate a cause) and is present in a minority of PE cases. [12] It can also result from acute changes associated with bronchospasm and pneumothorax. [6] Other EKG signs include a right bundle branch block [13] as well as T wave inversions in the anterior leads, which are "thought to be the consequence of an ischemic phenomenon due to low cardiac output in the context of RV dilation and strain." [13] Aside from echo and ECG, RV strain is visible with a CT scan of the chest and via cardiac magnetic resonance. [14]

See also

Notes

  1. ↑ The apical-four-chamber (A4C) view is best to visualize right heart strain by echo. [5]
  2. ↑ Indicative of a prominent S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III, [9] which is also known as the McGinn–White sign [6]

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Pulmonary embolism</span> Blockage of an artery in the lungs

Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood. Symptoms of a blood clot in the leg may also be present, such as a red, warm, swollen, and painful leg. Signs of a PE include low blood oxygen levels, rapid breathing, rapid heart rate, and sometimes a mild fever. Severe cases can lead to passing out, abnormally low blood pressure, obstructive shock, and sudden death.

<span class="mw-page-title-main">Tetralogy of Fallot</span> Type of congenital heart defect

Tetralogy of Fallot (TOF), formerly known as Steno-Fallot tetralogy, is a congenital heart defect characterized by four specific cardiac defects. Classically, the four defects are:

<span class="mw-page-title-main">Pulmonary heart disease</span> Medical condition

Pulmonary heart disease, also known as cor pulmonale, is the enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lungs.

<span class="mw-page-title-main">Pulmonary artery</span> Artery in pulmonary circulation carrying deoxygenated blood from heart to lungs

A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the main pulmonary artery or pulmonary trunk from the heart, and the smallest ones are the arterioles, which lead to the capillaries that surround the pulmonary alveoli.

<span class="mw-page-title-main">Chest pain</span> Discomfort or pain in the chest as a medical symptom

Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath. It can be divided into heart-related and non-heart-related pain. Pain due to insufficient blood flow to the heart is also called angina pectoris. Those with diabetes or the elderly may have less clear symptoms.

<span class="mw-page-title-main">Afterload</span> Pressure in the wall of the left ventricle during ejection

Afterload is the pressure that the heart must work against to eject blood during systole. Afterload is proportional to the average arterial pressure. As aortic and pulmonary pressures increase, the afterload increases on the left and right ventricles respectively. Afterload changes to adapt to the continually changing demands on an animal's cardiovascular system. Afterload is proportional to mean systolic blood pressure and is measured in millimeters of mercury.

<span class="mw-page-title-main">Arrhythmogenic cardiomyopathy</span> Medical condition

Arrhythmogenic cardiomyopathy (ACM), arrhythmogenic right ventricular dysplasia (ARVD), or arrhythmogenic right ventricular cardiomyopathy (ARVC), most commonly is an inherited heart disease.

<span class="mw-page-title-main">Atrial septal defect</span> Human heart defect present at birth

Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria of the heart. Some flow is a normal condition both pre-birth and immediately post-birth via the foramen ovale; however, when this does not naturally close after birth it is referred to as a patent (open) foramen ovale (PFO). It is common in patients with a congenital atrial septal aneurysm (ASA).

<span class="mw-page-title-main">Pulmonary hypertension</span> Medical condition

Pulmonary hypertension is a condition of increased blood pressure in the arteries of the lungs. Symptoms include shortness of breath, fainting, tiredness, chest pain, swelling of the legs, and a fast heartbeat. The condition may make it difficult to exercise. Onset is typically gradual.

<span class="mw-page-title-main">Ventricular septal defect</span> Medical condition

A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart. The extent of the opening may vary from pin size to complete absence of the ventricular septum, creating one common ventricle. The ventricular septum consists of an inferior muscular and superior membranous portion and is extensively innervated with conducting cardiomyocytes.

<span class="mw-page-title-main">Left ventricular hypertrophy</span> Medical condition

Left ventricular hypertrophy (LVH) is thickening of the heart muscle of the left ventricle of the heart, that is, left-sided ventricular hypertrophy and resulting increased left ventricular mass.

<span class="mw-page-title-main">Pulmonary artery catheter</span> Catheter for insertion into a pulmonary artery

A pulmonary artery catheter (PAC), also known as a Swan-Ganz catheter or right heart catheter, is a balloon-tipped catheter that is inserted into a pulmonary artery in a procedure known as pulmonary artery catheterization or right heart catheterization. Pulmonary artery catheterization is a useful measure of the overall function of the heart particularly in those with complications from heart failure, [[heart attack, arrythmias or pulmonary embolism. It is also a good measure for those needing intravenous fluid therapy, for instance post heart surgery, shock, and severe burns. The procedure can also be used to measure pressures in the heart chambers.

<span class="mw-page-title-main">Right bundle branch block</span> Heart block in the right ventricle

A right bundle branch block (RBBB) is a heart block in the right bundle branch of the electrical conduction system.

A transthoracic echocardiogram (TTE) is the most common type of echocardiogram, which is a still or moving image of the internal parts of the heart using ultrasound. In this case, the probe is placed on the chest or abdomen of the subject to get various views of the heart. It is used as a non-invasive assessment of the overall health of the heart, including a patient's heart valves and degree of heart muscle contraction. The images are displayed on a monitor for real-time viewing and then recorded.

<span class="mw-page-title-main">Valvular heart disease</span> Disease in the valves of the heart

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

<span class="mw-page-title-main">Right ventricular hypertrophy</span> Medical condition

Right ventricular hypertrophy (RVH) is a condition defined by an abnormal enlargement of the cardiac muscle surrounding the right ventricle. The right ventricle is one of the four chambers of the heart. It is located towards the lower-end of the heart and it receives blood from the right atrium and pumps blood into the lungs.

<span class="mw-page-title-main">Right axis deviation</span> Medical condition

The electrical axis of the heart is the net direction in which the wave of depolarization travels. It is measured using an electrocardiogram (ECG). Normally, this begins at the sinoatrial node ; from here the wave of depolarisation travels down to the apex of the heart. The hexaxial reference system can be used to visualise the directions in which the depolarisation wave may travel.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

<span class="mw-page-title-main">Endomyocardial biopsy</span> Invasive medical procedure to obtain small samples of heart muscle

Endomyocardial biopsy (EMB) is an invasive procedure used routinely to obtain small samples of heart muscle, primarily for detecting rejection of a donor heart following heart transplantation. It is also used as a diagnostic tool in some heart diseases.

References

  1. ↑ Weerakkody, Yuranga. "Right heart strain | Radiology Reference Article | Radiopaedia.org". radiopaedia.org. Retrieved 2016-07-12.
  2. ↑ Rudski, Lawrence G.; Lai, Wyman W.; Afilalo, Jonathan; Hua, Lanqi; Handschumacher, Mark D.; Chandrasekaran, Krishnaswamy; Solomon, Scott D.; Louie, Eric K.; Schiller, Nelson B. (2010-07-01). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography" (PDF). Journal of the American Society of Echocardiography. 23 (7): 685–713 (see 704), quiz 786–788. doi:10.1016/j.echo.2010.05.010. PMID   20620859.
  3. ↑ Koestenberger, Martin; Friedberg, Mark K.; Nestaas, Eirik; Michel-Behnke, Ina; Hansmann, Georg (2016-03-01). "Transthoracic echocardiography in the evaluation of pediatric pulmonary hypertension and ventricular dysfunction". Pulmonary Circulation. 6 (1): 15–29. doi:10.1086/685051. ISSN   2045-8932. PMC   4860554 . PMID   27162612.
  4. ↑ Shopp, Jacob D.; Stewart, Lauren K.; Emmett, Thomas W.; Kline, Jeffrey A. (2015-10-01). "Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis". Academic Emergency Medicine. 22 (10): 1127–1137. doi:10.1111/acem.12769. ISSN   1553-2712. PMC   5306533 . PMID   26394330.
  5. 1 2 3 Mike Blaivas (3 April 2014). Emergency Medicine, An Issue of Ultrasound Clinics. Elsevier Health Sciences. p. 229. ISBN   978-0-323-29021-0.
  6. 1 2 3 Houghton, Andrew R.; Gray, David (2014-06-04). Making Sense of the ECG: Cases for Self Assessment, Second Edition. CRC Press. p. 62. ISBN   9781444181852.
  7. ↑ Rogers, Robert L.; Scalea, Thomas; Geduld, Heike (2013-04-04). Vascular Emergencies: Expert Management for the Emergency Physician. Cambridge University Press. p. 208. ISBN   9781107035027.
  8. ↑ Walsh, Brooks M.; Moore, Christopher L. (2015-09-01). "McConnell's Sign Is Not Specific for Pulmonary Embolism: Case Report and Review of the Literature". The Journal of Emergency Medicine. 49 (3): 301–304. doi:10.1016/j.jemermed.2014.12.089. PMID   25986329.
  9. ↑ Kusumoto, Fred M. (2009-04-21). ECG Interpretation: From Pathophysiology to Clinical Application. Springer Science & Business Media. p. 259. ISBN   9780387888804.
  10. ↑ Warrell, Emeritus Professor of Tropical Medicine David; Cox, Timothy; Dwight, Jeremy; Firth, Consultant Physician and Nephrologist John (2016-06-16). Oxford Textbook of Medicine: Cardiovascular Disorders. Oxford University Press. p. 527. ISBN   9780198717027.
  11. ↑ Garcia, Tomas B.; Holtz, Neil (2011-11-15). 12-Lead ECG. Jones & Bartlett Publishers. p. 347. ISBN   9781449677893.
  12. ↑ Garcia, Tomas B.; Holtz, Neil (2011-11-15). 12-Lead ECG. Jones & Bartlett Publishers. p. 290. ISBN   9781449677893.
  13. 1 2 Digby, Geneviève C.; Kukla, Piotr; Zhan, Zhong-Qun; Pastore, Carlos A.; Piotrowicz, Ryszard; Schapachnik, Edgardo; Zareba, Wojciech; Bayés de Luna, Antonio; Pruszczyk, Piotr (2015-05-01). "The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper". Annals of Noninvasive Electrocardiology. 20 (3): 207–223. doi:10.1111/anec.12278. PMC   6931801 . PMID   25994548.
  14. ↑ Tadic, Marijana (2015-12-01). "Multimodality Evaluation of the Right Ventricle: An Updated Review". Clinical Cardiology. 38 (12): 770–776. doi:10.1002/clc.22443. ISSN   1932-8737. PMC   6490828 . PMID   26289321.
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