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AimsRight ventricular (RV) systolic dysfunction has been shown to be an independent predictor of clinical outcome in patients with chronic heart failure (CHF), and cardiac metaiodobenzylguanidine (MIBG) imaging also provides prognostic information. We aimed to evaluate the long‐term predictive value of combining RV systolic dysfunction and abnormal findings of cardiac MIBG imaging on outcome in CHF patients.Methods and resultsWe enrolled 63 CHF outpatients with left ventricular ejection fraction (EF) <40% in a prospective cohort study. At entry, RVEF was measured by radionuclide angiography. Furthermore, cardiac MIBG imaging was performed, and the cardiac MIBG washout rate (WR) was calculated. Reduced RVEF was defined as ≤37%, and abnormal WR was defined as >27%. The study endpoint was unplanned hospitalization for worsening heart failure (WHF) and cardiac death. During a follow‐up period of 8.9 ± 4.3 years, 19 of 63 patients had unplanned hospitalization for WHF, and 19 of 63 patients had cardiac death. In multivariate analysis, both WR and RVEF were independent predictors of unplanned WHF hospitalization, while WR was also an independent predictor of cardiac death. A risk‐stratification model based on independent predictors of unplanned WHF hospitalization separated the patients into those with low (absence of the predictors), intermediate (one of the predictors), and high (two or more of the predictors) risk of unplanned WHF hospitalization (P < 0.0001) or cardiac death (P = 0.0113).ConclusionsCardiac MIBG imaging provides incremental value when it is used along with RV systolic dysfunction to predict clinical outcome in patients with CHF.