TAPSE/RVSP ratio as an echocardiographic marker of residual risk in HFrEF patients receiving vericiguat

Background Vericiguat, the first-in-class soluble guanylate cyclase stimulator, represents a promising therapeutic option for patients with heart failure (HF), potentially improving clinical outcomes and quality of life, particularly among those who remain at high risk despite receiving guideline-directed medical therapy (GDMT). However, vericiguat may not be uniformly effective across all patient populations, and it remains unclear which subgroups derive the greatest benefit from this treatment. Purpose We aimed to evaluate the prognostic value of echocardiographic parameters for predicting adverse outcomes following vericiguat initiation in real-world HF patients receiving GDMT. Methods A total of 72 consecutive patients with heart failure (mean age 74.9 ± 10.9 years; 54% male) who initiated vericiguat therapy were included. Baseline transthoracic echocardiography was performed within 3 months prior to vericiguat initiation. The primary endpoint was a composite of cardiovascular death or heart failure hospitalization. Results During a median follow-up of 339 days, the composite outcome occurred in 25% of patients (n=18). Baseline comorbidities, including hypertension and diabetes, did not differ significantly between the event and non-event groups. Similarly, there were no statistical differences in the use of guideline-directed medical therapy or in the maintenance dose of vericiguat. The mean left ventricular ejection fraction (LVEF) and global longitudinal strain (LVGLS) of study population were 29.9 ± 8.1% and −8.78 ± 3.4, respectively. Most baseline echocardiographic parameters were comparable between groups (Figure 1). However, patients who experienced events had a significantly lower tricuspid annular plane systolic excursion (TAPSE) to right ventricular systolic pressure (RVSP) ratio (0.30 ± 0.15 vs. 0.40 ± 0.19, P=0.045). The predictive power of TAPSE/RVSP for the composite endpoint was modest (AUC=0.695, P=0.019), and the optimal cut-off value was 0.32. Kaplan–Meier analysis further demonstrated that patients with a TAPSE/RVSP ratio ≤0.32 experienced significantly worse outcomes, with a higher cumulative incidence of cardiovascular death or heart failure hospitalization (Figure 2). Conclusion In patients with heart failure receiving vericiguat on top of guideline-directed medical therapy, a lower TAPSE/RVSP ratio was associated with an increased risk of cardiovascular death or heart failure hospitalization. TAPSE/RVSP may serve as a simple and useful echocardiographic marker to stratify residual risk in this population.