Right ventricular uncoupling in heart failure with preserved ejection fraction: a simple parameter to predict long-term mortality?

Abstract

Abstract Introduction Several prognostic models have been developed for risk stratification of mortality in patients with acute heart failure (AHF). eRecent evidence suggests that the right ventricular (RV)-pulmonary artery (PA) uncoupling is associated with poor outcomes in heart failure. Patients with heart failure and preserved ejection fraction (HFpEF) are a heterogeneous population with a wide range of clinical outcomes. However, the prognostic utility of RV-PA uncoupling for predicting long-term mortality in these patients remains elusive. Objective To assess the prognostic value of right ventricle-pulmonary artery coupling for long-term mortality in hospitalized patients with HFpEF. Methods Retrospective analysis of a consecutive, prospective, single-center cohort. Adult patients hospitalized between 2015 and 2020 with a primary diagnosis of AHF and left ventricular ejection fraction (LVEF) >40% were included. The primary endpoint was long-term all-cause mortality. Ventricular uncoupling was assessed as the ratio of tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) estimated from an echocardiogram performed within 3 months of the index hospitalization. Univariable Cox proportional hazards regression models were used to calculate hazard ratios (HR), and multivariable Cox regression was performed with previously analyzed covariates: age, sex, atrial fibrillation, renal dysfunction and E/e'. Results Of 465 patients with HFpEF, 361 (77%) PASP and TAPSE could be estimated simultaneously. During a mean follow-up of 20.9 months, the primary outcome event occurred in 100 patients (27.7%). The optimal cut-off for the primary endpoint was TAPSE/PASP=0.38. Univariable Cox regression showed that RV-PA uncoupling was associated with the primary endpoint of long-term mortality (hazard ratio [HR] 1.96 [95% CI, 1.32-2.92], P=0.001). Kaplan-Meier analysis showed that patients with a ratio <0.38 were at high risk of all-cause mortality (Figure 1). Multivariable analysis also showed that RV-PA uncoupling was significantly associated with long term mortality independent of age, sex, atrial fibrillation, renal dysfunction and E/e' (HR 2.21 [95% CI, 1.26-3.81], P=0.005). Conclusions In patients hospitalized for AHF with preserved ejection fraction, RV-PA uncoupling as determined by the TAPSE/PASP ratio was independently associated with long-term all-cause mortality. TAPSE/PASP was associated with mortality independently of age, sex, renal function, atrial fibrillation and diastolic dysfunction. This simple echocardiographic parameter may identify a population at higher risk for events during follow-up.Kaplan-Meier for all-cause mortality