Biventricular Heart Failure Diagnosis and Management

Clinical Presentation and Diagnosis

The American College of Cardiology suggests that dyspnea and cough indicate left ventricular dysfunction causing pulmonary venous hypertension and pulmonary edema, while bipedal edema reflects elevated right atrial pressure and systemic venous congestion, and jaundice suggests hepatic congestion from elevated right-sided pressures causing congestive hepatopathy (cardiac cirrhosis) 1, 2, 3
The American College of Cardiology recommends using natriuretic peptides (BNP >100 pg/mL or NT-proBNP >300 pg/mL if hospitalized or >125 pg/mL if ambulatory) to confirm heart failure diagnosis, with a strength of evidence level of I (high) 4, 1
Echocardiography is essential to assess both left ventricular ejection fraction and right ventricular function, evaluate for structural/functional cardiac abnormalities, and guide therapy, according to the American College of Cardiology 4, 1

The American College of Cardiology states that liver function tests, including elevated transaminases and bilirubin, confirm hepatic congestion and distinguish it from primary liver disease, with a strength of evidence level of IIa (moderate) 3
Physical examination findings, such as S3 gallop, jugular venous distension, and hepatomegaly, indicate ventricular dysfunction, elevated right-sided pressures, and advanced right-sided heart failure, respectively, as suggested by the American College of Cardiology 2, 5

The American College of Cardiology recommends Guideline-Directed Medical Therapy (GDMT) based on ejection fraction, including quadruple therapy for HFrEF (EF <40%) and SGLT2 inhibitors for HFpEF (EF ≥50%), with a strength of evidence level of I (high) 5, 4
Optimizing diuresis and monitoring liver function are crucial in addressing hepatic congestion, according to the American College of Cardiology, with a strength of evidence level of IIa (moderate) 1, 3

The American College of Cardiology suggests referring patients to cardiology for optimization of GDMT, advanced diagnostic testing, and consideration of device therapy, with a strength of evidence level of I (high) 5, 4
Common pitfalls include attributing all symptoms to primary liver disease, inadequate diuresis, ignoring right ventricular function, and delayed echocardiography, as warned by the American College of Cardiology, with a strength of evidence level of III (low) 1, 4