Key result
GDMT up-titration improves RV-PA coupling, and low follow-up TAPSE/sPAP predicts ~6-fold higher death or HF risk.
Why the study?
Data on the effect of GDMT up-titration on right ventricular function remain sparse in heart failure with reduced ejection fraction.
Does GDMT up-titration improve RV-PA coupling, and is TAPSE/sPAP associated with reduced all-cause death or HF hospitalization in patients with LVEF <50%?
Cohort (n=291)
No
Does GDMT up-titration improve RV-PA coupling, and is TAPSE/sPAP associated with reduced all-cause death or HF hospitalization in patients with LVEF <50%?
GDMT up-titration improves RV-PA coupling, and a low TAPSE/sPAP at follow-up is a strong independent predictor of mortality or HF hospitalization in patients with HFrEF.
Supports serial TAPSE/sPAP assessment during GDMT up-titration in HFrEF; hypothesis-generating for RV-PA coupling as therapeutic target.
Background and Aims Up-titration of guidelines-directed medical therapy (GDMT) is known to enhance left ventricular function in heart failure (HF) with reduced ejection fraction. However, its effect on right ventricular (RV) function remains sparse. We aimed to assess the impact of GDMT up-titration on the RV, especially RV to pulmonary artery (RV-PA) coupling, and its prognostic value in these patients. Methods and Results All consecutive patients (n=291) with left ventricular ejection fraction (LVEF) <50% followed for GDMT up-titration in a dedicated HF-clinic in a tertiary center from January 2019 to June 2022 with an echocardiography at baseline (before up-titration) and at follow up (end of up-titration) were included: median age 65 (55-74) years, 24% of female. Ischemic cardiomyopathy was the main cause of HF (47%), LVEF 30% (22-34). After 2 years, fourty-nine patients (16.8%) reached the primary endpoint (all-cause death or hospitalization for acute HF). GDMT up-titration significantly improved RV size and function (all, p<0.001), including RV-PA coupling assessed by TAPSE/sPAP (0.62 vs. 0.81 mm/mmHg, p<0.001). TAPSE/sPAP <0.65 mm/mmHg at follow-up remained associated with the primary endpoint after adjustment with comorbidities (HR=5.9, 95%CI[2.8–12.1], p<0.001), clinical and biological severity (HR=6.4, 95%CI[2.4–17.8], p<0.001), and echocardiography (HR=3.6, 95%CI[1.6–8.4], p=0.002). In addition, TAPSE/sPAP was associated with an incremental prognostic value (C-index improvement, p<0.01, Figure D), over and above prognostic factors, including LVEF (Figure). Patients with low TAPSE/sPAP, at baseline (Figure A), at follow-up (Figure B) or patients with the lowest delta (i.e., follow-up minus baseline) improvement had lower survival (log-rank p<0.01). Conclusion This study highlights the independent and incremental prognostic value of TAPSE/sPAP in HFrEF during GDMT up-titration, suggesting to also consider RV-PA coupling with echocardiography as a treatment goal.
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Fauvel et al. (2025) conducted a cohort in Heart failure with reduced ejection fraction (n=291). TAPSE/sPAP <0.65 mm/mmHg at follow-up was evaluated on all-cause death or hospitalization for acute HF (HR 5.9, 95% CI 2.8-12.1, p=<0.001). TAPSE/sPAP <0.65 mm/mmHg at follow-up during GDMT up-titration was strongly associated with an increased risk of all-cause death or acute HF hospitalization (HR 5.9; 95% CI 2.8-12.1; p<0.001).
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