Hemodynamic Indices of Right Ventricular Function are Associated with Adverse Clinical Outcomes Across Heart Failure Subtypes

While right ventricular dysfunction (RVD) is critical to the progression of heart failure (HF), the prevalence and prognostic implications of RVD across HF subtypes remains poorly understood. We aimed to characterize differences in hemodynamic indices of RVD among patients with HF with preserved (HFpEF, EF≥50%) vs reduced (HFrEF, EF<50%) ejection fraction and examine associations of RVD with longitudinal clinical outcomes. We identified patients with prevalent HF undergoing clinically indicated right heart catheterization at Massachusetts General Hospital (2005-2016). We examined three RV hemodynamic indices: right atrial to wedge pressure ratio (RA/PCWP), RV stroke work index (RVSWI), and pulmonary artery pulsatility index (PAPi). We used multivariable Cox models to examine the association of each index with HF hospitalizations (HFH) and death. Of 2,062 patients, 1,242 (60%) had HFrEF and 820 (40%) had HFpEF; 56% of individuals with HFrEF and 53% with HFpEF met at least one hemodynamic criterion for RVD. In HFrEF, lower PAPi was associated with greater risk of HFH (HR 0.84 [0.77, 0.92]), and higher RVSWI was associated with greater risk of death (HR 1.17, [1.07, 1.27], all p<0.001). By contrast, only higher RA/PCWP was associated with greater risk of death in HFpEF (HR 1.11 (1.00, 1.22); p=0.046). Hemodynamic RVD is common in both HFrEF and HFpEF, and hemodynamic measures of RV function are associated with greater risk of adverse outcomes. Importantly, the prognostic value of RV indices varied by HF subtype, highlighting key differences in the role of RVD in HFrEF vs HFpEF.