Right Ventricular Global Constructive Work as an Echocardiographic Predictor of Worsening Heart Failure

Aims Worsening heart failure (WHF) is a pivotal event in the trajectory of chronic HF, yet early risk stratification remains challenging. Echocardiographic right ventricular myocardial work (RVMW), a pressure–strain–integrated index, may offer incremental prognostic value beyond conventional echocardiographic and biomarker-based markers. This study assessed whether right ventricular global constructive work (RVGCW), the principal component of RVMW, predicts WHF and cardiovascular mortality. Methods and Results In this prospective study, we enrolled 215 ambulatory patients with chronic heart failure (NYHA II–IV), encompassing HFrEF, HFmrEF, and HFpEF, all in sinus rhythm and receiving guideline-directed medical therapy. Comprehensive transthoracic echocardiography was performed using a GE Vivid E95 system with offline analysis (EchoPAC v204). Right ventricular myocardial work (RVMW) was quantified using a non-invasive pressure–strain loop methodology, and right ventricular global constructive work (RVGCW) was prespecified as the primary RVMW parameter of interest. RVGCW was derived from right ventricular pressure–strain loops integrating RV global strain and estimated pulmonary pressures. Patients were followed for 24 months with scheduled 3-month assessments and additional visits for suspected worsening heart failure (WHF). The primary endpoint was composite WHF, defined as heart failure hospitalization or adjudicated subclinical WHF. Baseline RVGCW was significantly lower in patients who developed WHF compared with those who did not (607±48 vs. 648±52 mmHg%, p<0.001). In multivariable Cox models adjusting for NT-proBNP, left atrial reservoir strain, left ventricular global longitudinal strain, left atrial volume index, TAPSE/sPAP, and RV strain, RVGCW remained independently associated with WHF (HR 0.978, 95% CI 0.973–0.998, p=0.014). In receiver operating characteristic analysis, a cohort-derived RVGCW threshold demonstrated high discrimination for WHF (AUC 0.90). Conclusion Echocardiographic right ventricular global constructive work is a strong, independent predictor of worsening heart failure and provides substantial incremental prognostic information beyond traditional markers; its association with cardiovascular mortality was exploratory.