What question did this study set out to answer?

To assess the prevalence of right ventricular systolic dysfunction using cardiovascular magnetic resonance imaging and evaluate its relationship with clinical outcomes in heart failure with preserved ejection fraction.

July 31, 2020International journal of cardiac imagingOpen Access

Prevalence of right ventricular dysfunction and prognostic significance in heart failure with preserved ejection fraction

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Heart failure with preserved ejection fraction (HFpEF) (n=183). Intervention: Right ventricular systolic dysfunction (RVEF < 47%) vs. Absence of right ventricular dysfunction. Primary outcome: Composite of all-cause mortality or heart failure hospitalization (HR 3.946, 95% CI 1.878-8.290, p=0.0001).

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Key result

Right ventricular dysfunction was independently associated with a nearly four-fold increased risk of death or heart failure hospitalization in patients with heart failure with preserved ejection fraction (HR 3.946).

Why the study?

Data characterizing right ventricular performance in HFpEF using gold-standard cardiovascular magnetic resonance imaging were limited.

Does right ventricular systolic dysfunction assessed by CMR predict adverse outcomes in patients with HFpEF?

Key Points

To assess the prevalence of right ventricular systolic dysfunction using cardiovascular magnetic resonance imaging and evaluate its relationship with clinical outcomes in heart failure with preserved ejection fraction.
Evaluated 183 subjects (135 HFpEF patients and 48 age- and sex-matched controls; NCT03050593) using cardiovascular magnetic resonance, transthoracic echocardiography, blood sampling, and six-minute walk testing.
Followed patients over a median duration of 1429 days for a primary composite endpoint of all-cause mortality or heart failure hospitalization.
Right ventricular dysfunction (RVEF < 47%) occurred in 19% of HFpEF patients and significantly increased the rate of the composite endpoint (Log-Rank p = 0.001; total composite events 47% [n = 64], with 22 deaths and 42 hospitalizations).
Multivariable Cox regression identified right ventricular dysfunction as an independent predictor of adverse outcomes (adjusted HR 3.946, 95% CI 1.878–8.290, p = 0.0001), along with indexed extracellular volume (HR 1.742, 95% CI 1.176–2.579, p = 0.006) and E/E' (HR 1.745, 95% CI 1.230–2.477, p = 0.002).

Study Design

Type

Observational (n=183)

Multicenter

Structured PICO

Does right ventricular systolic dysfunction assessed by CMR predict adverse outcomes in patients with HFpEF?

Population

135 patients with heart failure with preserved ejection fraction and 48 age- and sex-matched controls, with a mean age of 72 years, followed for a median of 1429 days.

Exposure

Presence of right ventricular systolic dysfunction (RVD), defined as right ventricular ejection fraction < 47% assessed by cardiovascular magnetic resonance imaging (CMR).

Comparator

HFpEF patients without right ventricular systolic dysfunction (RVEF ≥ 47%).

Outcome

Composite of all-cause mortality or heart failure hospitalization (defined as a hospital admission for HF which required diuretic, inotropic or intravenous nitrate therapy).composite

Main Result

Hazard Ratio: 3.946 (95% CI 1.878–8.29)

p-value: p=0.0001

Right ventricular systolic dysfunction assessed by CMR is present in nearly 20% of HFpEF patients and is a strong independent predictor of mortality and heart failure hospitalization.

Limitations

Single centre, observational study design precludes determination of causality.
Lack of outcome data categorizing deaths as cardiovascular versus non-cardiovascular.
Definition of HFpEF was not in accordance with the latest European Society of Cardiology guidelines (diastolic dysfunction and elevated natriuretic peptides were not required).
Exclusion of patients with severe lung disease may have resulted in a lower reported prevalence of RVD than in the general HFpEF population.
Did not calculate estimates of pulmonary artery pressures or quantify tricuspid regurgitation severity.

Implication

RVD on CMR signals higher HFpEF risk; leaves open whether routine RV assessment refines stratification or management.

Abstract

There is a paucity of data characterizing right ventricular performance in heart failure with preserved ejection fraction (HFpEF) using the gold standard of cardiovascular magnetic resonance imaging (CMR). We aimed to assess the proportion of right ventricular systolic dysfunction (RVD) in HFpEF and the relation to clinical outcomes. As part of a single-centre, prospective, observational study, 183 subjects (135 HFpEF, and 48 age- and sex-matched controls) underwent extensive characterization with CMR. transthoracic echocardiography, blood sampling and six-minute walk testing. Patients were followed for the composite endpoint of death or HF hospitalization. RVD (defined as right ventricular ejection fraction < 47%) controls was present in 19% of HFpEF. Patients with RVD presented more frequently with lower systolic blood pressure, atrial fibrillation, radiographic evidence of pulmonary congestion and raised cardiothoracic ratio and larger right ventricular volumes. During median follow-up of 1429 days, 47% (n = 64) of HFpEF subjects experienced the composite endpoint of death (n = 22) or HF hospitalization (n = 42). RVD was associated with an increased risk of composite events (Log-Rank p = 0.001). In multivariable Cox regression analysis, RVD was an independent predictor of adverse outcomes (adjusted Hazard Ratio [HR] 3.946, 95% CI 1.878-8.290, p = 0.0001) along with indexed extracellular volume (HR 1.742, CI 1.176-2.579, p = 0.006) and E/E' (HR 1.745, CI 1.230-2.477, p = 0.002). RVD as assessed by CMR is prevalent in nearly one-fifth of HFpEF patients and is independently associated with death and/or hospitalization with HF.The trial was registered retrospectively on ClinicalTrials.gov (Identifier: NCT03050593). The date of registration was February 06, 2017.

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Cite This Study

Kanagala et al. (2020) conducted an observational in Heart failure with preserved ejection fraction (HFpEF) (n=183). Right ventricular systolic dysfunction (RVEF < 47%) vs. Absence of right ventricular dysfunction was evaluated on Composite of all-cause mortality or heart failure hospitalization (HR 3.946, 95% CI 1.878-8.290, p=0.0001). Right ventricular dysfunction was independently associated with a nearly four-fold increased risk of death or heart failure hospitalization in patients with heart failure with preserved ejection fraction (HR 3.946).

synapsesocial.com/papers/6a90368fc7b7d4543f89ddbb https://doi.org/10.1007/s10554-020-01953-y