A 41-year-old man comes to the emergency department because of fatigue, worsening abdominal discomfort, and progressive swelling of his legs for 3 months. The swelling is worse in the evenings. His only medication is ibuprofen for occasional joint pain. The patient does not smoke and drinks 2–3 beers each weekend. His temperature is 36°C (96.8°F), pulse is 88/min, respirations are 18/min, and blood pressure is 130/80 mm Hg. Pulmonary examination shows no abnormalities. Abdominal examination shows a mildly distended abdomen with shifting dullness. The liver is palpated 2–3 cm below the right costal margin. When pressure is applied to the right upper quadrant, the patient's jugular veins become visibly distended for 15 seconds. The 2nd and 3rd metacarpophalangeal joints of both hands are tender to palpation. There is 2+ edema in the lower extremities. Which of the following is the most likely underlying cause of this patient's edema?

Impaired relaxation of the right ventricle

Reduced glomerular filtration rate

Macrovesicular steatosis of the liver

Dermal deposition of glycosaminoglycans

Impaired hepatic protein synthesis

A 38-year-old woman comes to the physician because of an 8-week history of shortness of breath and dull chest pain. She has a history of antiphospholipid syndrome. Physical examination shows jugular venous distention. Right heart catheterization shows a mean pulmonary arterial pressure of 30 mm Hg and a pulmonary capillary wedge pressure of 10 mm Hg. Further evaluation is most likely to show which of the following?

Constriction of the renal afferent arteriole

Mitral valve leaflet thickening

Decreased left ventricular contractility

Six days after undergoing a left hemicolectomy for colorectal carcinoma, a 59-year-old man collapses in the hospital hallway and is unconscious for 30 seconds. Afterwards, he complains of shortness of breath and chest pain with deep inhalation. He has hypertension and hyperlipidemia. He smoked one pack of cigarettes daily for 35 years but quit prior to admission to the hospital. He does not drink alcohol. He is in distress and appears ill. His temperature is 36.5°C (97.7°F), blood pressure is 80/50 mm Hg, and pulse is 135/min and weak. Oxygen saturation is 88% on room air. Physical examination shows elevated jugular venous distention. Cardiac examination shows a regular, rapid heart rate and a holosystolic murmur that increases during inspiration. His abdomen is soft and mildly tender to palpation around the surgical site. Examination of his extremities shows pitting edema of the left leg. His skin is cold and clammy. Further examination is most likely to reveal which of the following findings?

Dilated right ventricular cavity

Reduced regional ventricular wall motion

Rapid, aberrant contractions of the atria

Stenosis of the carotid arteries

Anechoic space between pericardium and epicardium

A 64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes presents to his primary care physician with increasing shortness of breath and ankle swelling over the past month. Which of the following findings is more likely to be seen in left-sided heart failure and less likely to be seen in right-sided heart failure?

Basilar crackles on pulmonary auscultation

Increased ejection fraction on echocardiogram

A 61-year-old man comes to the physician for shortness of breath and chest discomfort that is becoming progressively worse. He has had increasing problems exerting himself for the past 5 years. He is now unable to walk more than 50 m on level terrain without stopping and mostly rests at home. He has smoked 1–2 packs of cigarettes daily for 40 years. He appears distressed. His pulse is 85/min, blood pressure is 140/80 mm Hg, and respirations are 25/min. Physical examination shows a plethoric face and distended jugular veins. Bilateral wheezing is heard on auscultation of the lungs. There is yellow discoloration of the fingers on the right hand and 2+ lower extremity edema. Which of the following is the most likely cause of this patient's symptoms?

Elevated pulmonary artery pressure

Decreased intrathoracic gas volume

Right heart failure for USMLE Step 3: High-Yield Internal Medicine Lessons

Etiology & Pathophysiology - The Pressure Backlog

Most Common Cause: Left heart failure (LHF). Pressure backs up from the failing LV into the pulmonary circulation, increasing RV afterload.
Other Causes (leading to Cor Pulmonale):
- Chronic lung disease (COPD, ILD)
- Idiopathic pulmonary arterial hypertension
- Recurrent pulmonary emboli
- Right-sided valvular disease (e.g., tricuspid regurgitation, pulmonic stenosis)

Pathophysiology of increased capillary hydrostatic pressure

⭐ Cor pulmonale is right heart failure arising from a primary disorder of the respiratory system, creating pulmonary hypertension. RHF due to LHF or congenital heart disease is not cor pulmonale.

Clinical Presentation - Systemic Swamp

Failure of the right ventricle causes a backup of blood in the systemic venous circuit, leading to fluid overload.

Jugular Venous Distension (JVD): Hallmark of ↑ CVP.
- JVP >8 cm H₂O.
- Positive hepatojugular reflux (HJR).
Dependent Pitting Edema:
- Ankles and presacral area.
- Can progress to anasarca.
Congestive Hepatopathy:
- Tender hepatomegaly (RUQ pain).
- Pulsatile liver.
- Chronic congestion → "cardiac cirrhosis."
GI Tract Congestion:
- Ascites.
- Anorexia, nausea, early satiety.

⭐ Kussmaul's Sign: A paradoxical rise in JVP on inspiration, indicating limited RV filling. Seen in severe RHF and constrictive pericarditis.

📌 Mnemonic (AW HEAD): Anorexia, Weight gain, Hepatomegaly, Edema, Ascites, Distended neck vein.

Pitting Edema in Lower Extremities

Diagnosis - The Right-Sided Reveal

Physical Exam: Key findings include:
- Jugular Venous Distension (JVD)
- Positive Hepatojugular Reflux (HJR)
- Symmetrical peripheral pitting edema
- Tender hepatomegaly & ascites
Echocardiogram (Best Initial Test):
- Shows RV dilation & hypokinesis.
- Estimates RV systolic pressure (RVSP) & pulmonary artery pressure.
- Assesses for tricuspid regurgitation.
Right Heart Catheterization (Gold Standard):
- Confirms diagnosis and quantifies severity.
- Measures: ↑ CVP, ↑ PVR, normal/low PCWP.

Pathophysiology, Diagnosis, and Management of RV Dysfunction

⭐ Kussmaul's Sign: A paradoxical rise in JVP during inspiration is highly specific for impaired RV filling, seen in severe RHF or constrictive pericarditis.

Management - Diuresis & Decongestion

Primary Goal: Relieve congestive symptoms (peripheral edema, ascites, JVD) by reducing central venous pressure through fluid removal.
First-line Therapy: IV Loop Diuretics for acute decompensation (e.g., Furosemide, Bumetanide).
- IV route preferred due to poor oral bioavailability from gut edema.
- Monitor: Daily weights, strict I/Os, electrolytes (K⁺, Mg²⁺), and renal function (BUN, Cr).
Strategy for Diuretic Resistance:

⭐ For diuretic resistance, administer a thiazide (e.g., metolazone) 30 minutes before a loop diuretic. This timing maximizes sequential nephron blockade, preventing distal tubule hypertrophy from compensating for the loop's effect.

Ultrafiltration: A mechanical fluid removal option for patients with severe, refractory volume overload, especially with worsening renal function (cardiorenal syndrome).

High‑Yield Points - ⚡ Biggest Takeaways

The most common cause of right heart failure (RHF) is left-sided heart failure.

Isolated RHF is most frequently caused by cor pulmonale, often secondary to COPD.

Clinical manifestations are dominated by systemic venous congestion, not pulmonary symptoms.

Key signs include jugular venous distension (JVD), pitting lower extremity edema, and congestive hepatosplenomegaly.

Kussmaul's sign (a paradoxical rise in JVP on inspiration) is a characteristic finding.

Echocardiography is the best initial test; right heart catheterization is the gold standard for diagnosis.

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