The Right Ventricle Drives the Progression of Heart Failure

We read with great interest the findings from Greene and colleagues described in their article ‘Hospitalization for recently diagnosed versus worsening chronic heart failure’.1 The post-hoc analysis of the ASCEND-HF trial demonstrated that the duration of the history of heart failure (HF) diagnosis, before the index hospitalization, was independently associated with post-discharge death and rehospitalization. The Authors showed that recently diagnosed (or de novo) HF patients had better outcomes than patients presenting with chronic decompensated HF. In this study, it is interesting to note a gradual deterioration of renal function and increasing prevalence of peripheral oedema as well as jugular venous distension the longer the history of HF. These signs seem suggestive of an additive or greater right ventricular dysfunction the longer the history of HF. Our hypothesis is supported by the fact that pulmonary rales were more frequent in recently diagnosed HF, implying predominant left-sided heart failure, while worsening chronic HF is rather a biventricular dysfunction, as has been recently shown.2 To this day, there are little data concerning the natural evolution of right ventricular failure (RVF).3 It is known that RVF develops in HF with both reduced and preserved ejection fraction, with prevalence ranging from 21% to 75%.4 More importantly, the occurrence of RVF is independently associated with a dismal prognosis in all HF patient subgroups.5 Based on the paper of Greene et al.,1 we suggest that the relationship between HF chronicity and post-discharge outcomes might be, at least partly, due to the eventual progression of RVF. Even though the interaction between HF duration and outcomes persisted after adjustment for renal function as well as other covariates, it would be of interest to see echocardiographic parameters of right ventricular function. Baseline parameters of hepatic function are equally relevant and could have provided valuable information on right ventricular dysfunction. Upcoming studies should focus on evaluating right ventricular function in order to improve risk stratification of chronic HF. We further suggest clinical and imaging signs of RVF as an additional prognostic dimension to be considered while designing future clinical trials. Conflicts of interest: A.M. received personal fees from Novartis, Orion, Roche, Servier, ZS Pharma, Cardiorentis (Steering Committee), Adrenomed (Steering Committee), a research grant from Adrenomed, MyCartis (Steering Committee), and Critical Diagnostics. J.C. received speaker and investigator fees from Servier, Amgen Inc., Bayer, and Berlin-Chemie AG. The work of J.M. and J.C. was supported by the Research Council of Lithuania, grant number MIP-049/2015.