Right Ventricular Dysfunction Predicts Outcome in Acute Heart Failure

Abstract

AimThe severity of cardiac impairment in acute heart failure (AHF) predicts outcome, but challenges remain to identify prognostically important non-invasive parameters of cardiac function. Left ventricular ejection fraction (LVEF) is relevant, but only in those with reduced LV systolic function. We aimed to assess the standard and advanced parameters of left and right ventricular (RV) function from echocardiography in predicting long-term outcomes in AHF.MethodsA total of 418 consecutive AHF patients presenting over 12 months were prospectively recruited and underwent bedside echocardiography within 24 h of recruitment. We retrospectively assessed 8 RV and 5 LV echo parameters of the cardiac systolic function to predict 2-year mortality, using both guideline-directed and study-specific cutoffs, based on the maximum Youden indices via ROC analysis. For the RV, these were the tricuspid annular plane systolic excursion, RV fractional area change, tissue Doppler imaging (TDI) peak tricuspid annular systolic wave velocity, both peak- and end-systolic RV free wall global longitudinal strain (RV GLS) and strain rate (mean RV GLSR), RV ejection fraction (RVEF) derived from a 2D ellipsoid model and the ratio of the TAPSE to systolic pulmonary artery pressure (SPAP). For the LV, these were the LVEF, mitral regurgitant ΔP/Δt (MR dP/dt), the lateral mitral annular TDI peak systolic wave velocity, LV GLS, and the LV GLSR.ResultsA total of 7/8 parameters of RV systolic function were predictive of 2-year outcome, with study cutoffs like international guidelines. A cutoff of < −1.8 s–1 mean RV GLSR was associated with worse outcome compared to > −1.8 s–1 [HR 2.13 95% CI 1.33–3.40 (p = 0.002)]. TAPSE:SPAP of > 0.027 cm/mmHg (vs. < 0.027 cm/mmHg) predicted worse outcome [HR 2.12 95% CI 1.53–2.92 (p < 0.001)]. A 3-way comparison of 2-year mortality by LVEF from the European Society of Cardiology (ESC) guideline criteria of LVEF > 50, 41–49, and < 40% was not prognostic [38.6% vs. 30.9 vs. 43.9% (p = 0.10)]. Of the 5 parameters of LV systolic function, only an MR dP/dt cutoff of < 570 mmHg was predictive of adverse outcome [HR 1.63 95% CI 1.01–2.62 (p = 0.047)].ConclusionWith cutoffs broadly like the ESC guidelines, we identified RV dysfunction to be associated with adverse prognosis, whereas LVEF could not identify patients at risk.

The prognostic value of right ventricular longitudinal strain in heart failure: a systematic review and meta-analysis

“…From the initial 1,292 studies identified based on the search strategy, 24 relevant eligible full-text articles were included [ 5 – 8 , 14 – 33 ]. Nine of the studies were excluded from the meta-analysis due to unreported HR, or because outcomes for RV strain were not assessed as continuous variables [ 14 , 16 – 20 , 23 , 26 , 33 ]. Overall, the risk of bias was considered to be low or moderate in the included studies (Table S2 of the supplementary appendix).…”

“…The overall follow-up ranged from 7.5 (range; 1.5–13.5) to 97 (range; 53–145) months. In terms of population characteristics 11 studies included only patients with HF with reduced EF (HFrEF) [ 5 , 7 , 8 , 14 , 17 , 18 , 25 , 28 – 30 , 32 ], 2 studies included HFrEF and HF with mildly reduced EF patients (HFmrEF) [ 20 , 21 ], in 1 study patients had only HF with preserved EF (HFpEF) [ 26 ], and the rest 10 included the whole range of LVEF [ 6 , 15 , 16 , 19 , 22 – 24 , 27 , 31 , 33 ]. Four studies investigated solely subjects with acute decompensated HF [ 6 , 14 , 23 , 33 ], while the rest included clinically stable HF patients or mixed cohorts.…”

“…In terms of population characteristics 11 studies included only patients with HF with reduced EF (HFrEF) [ 5 , 7 , 8 , 14 , 17 , 18 , 25 , 28 – 30 , 32 ], 2 studies included HFrEF and HF with mildly reduced EF patients (HFmrEF) [ 20 , 21 ], in 1 study patients had only HF with preserved EF (HFpEF) [ 26 ], and the rest 10 included the whole range of LVEF [ 6 , 15 , 16 , 19 , 22 – 24 , 27 , 31 , 33 ]. Four studies investigated solely subjects with acute decompensated HF [ 6 , 14 , 23 , 33 ], while the rest included clinically stable HF patients or mixed cohorts. Ten of the included studies reported data on both RV GLS and RV FWLS [ 7 , 8 , 16 , 19 , 21 , 25 , 26 , 29 – 31 ], 11 studies assessed only RV FWLS [ 5 , 14 , 17 , 20 , 22 – 24 , 27 , 28 , 32 , 33 ], and 3 studies evaluated only RV GLS [ 6 , 15 , 18 ].…”

“…Four studies investigated solely subjects with acute decompensated HF [ 6 , 14 , 23 , 33 ], while the rest included clinically stable HF patients or mixed cohorts. Ten of the included studies reported data on both RV GLS and RV FWLS [ 7 , 8 , 16 , 19 , 21 , 25 , 26 , 29 – 31 ], 11 studies assessed only RV FWLS [ 5 , 14 , 17 , 20 , 22 – 24 , 27 , 28 , 32 , 33 ], and 3 studies evaluated only RV GLS [ 6 , 15 , 18 ]. Most studies used General Electric (GE) Healthcare (n = 16) for the echocardiographic analysis, while 2 used only Phillips and 3 used other vendors.…”