Right heart strain

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]

When using an echocardiograph (echo) to visualize the heart,[a] 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[b] 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]

  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. ^ a b c Mike Blaivas (3 April 2014). Emergency Medicine, An Issue of Ultrasound Clinics. Elsevier Health Sciences. p. 229. ISBN 978-0-323-29021-0.
  6. ^ a b c 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. ^ a b 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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