Unmasking right ventricular dysfunction in HFpEF through diuretic-induced decongestion

Introduction Heart failure with preserved ejection fraction (HFpEF) remains a major clinical challenge. HFpEF is often associated with alterations in right ventricular and atrial function, which have been linked to adverse clinical outcomes. Diuretic therapy is commonly used to manage volume overload and symptoms in patients with HFpEF. However, the effects of diuretic therapy on right heart function are not well documented. This study aims to evaluate the impact of diuretic therapy—and thereby volume reduction—on right heart function in hospitalized patients with HFpEF admitted for decompensated heart failure. Methods A total of 67 patients with an ejection fraction ≥50%, who were hospitalized for decompensated heart failure between January 2020 and 2022, were included in the study. Transthoracic echocardiographic images were obtained before and after diuretic therapy. The patients’ volume status was assessed using physical examination, proBNP levels, and clinical symptoms. Right heart function was evaluated according to ASE and EACVI guidelines, and apical images of the right ventricle and right atrium were recorded for speckle-tracking analysis. Results Right ventricular echocardiographic parameters were analyzed before and after diuretic therapy. No statistically significant change was observed in right ventricular and atrial diameters. Fractional area change of the right ventricle decreased from 39.7 ± 9.2% to 38.4 ± 9.4% (p = 0.41), which was not statistically significant. Tricuspid annular plane systolic excursion (TAPSE) significantly decreased from 17.9 ± 4 cm to 15.6 ± 3.9 cm (p = 0.006). Right ventricular global longitudinal strain worsened from -19.9 ± 3.7% to -17.8 ± 3.9% (p = 0.010), and free wall strain decreased from -21.7 ± 5% to -19.1 ± 4.7% (p = 0.008). Right atrial reservoir strain decreased from 38.1 ± 10.5% to 34.2 ± 9.9% (p = 0.003), while contraction strain declined from -16.8 ± 5.9% to -13.7 ± 5.8% (p = 0.009). Right atrial conduit strain remained largely unchanged, with values of 21.9 ± 8.8% before and 21.0 ± 8.2% after therapy (p = 0.721). Discussion Our findings suggest that echocardiographic evaluation of right ventricular function in HFpEF patients during volume overload may overestimate actual myocardial performance. In hypervolemic states, increased preload may transiently enhance right ventricular contractility via the Frank-Starling mechanism, masking underlying dysfunction. Following diuretic therapy, the reduction in preload may unmask subclinical right heart dysfunction and better reflect true contractile capacity. Therefore, when assessing right ventricular function in HFpEF, clinicians should be aware that hypervolemia can lead to an overestimation of myocardial performance.