Key result
Right ventricular dysfunction affects up to ~33% of HFpEF patients and independently predicts worse outcomes.
Why the study?
Although HFpEF was historically viewed as a left-centric diastolic disorder, emerging evidence identifies right ventricular dysfunction and impaired ventriculo-arterial coupling as central drivers of adverse clinical outcomes, prompting a synthesis of mechanisms, diagnostics, and phenotype-specific therapies.
Right ventricular dysfunction and ventriculo-arterial uncoupling are prevalent prognostic markers in HFpEF, underscoring the need for routine biventricular and RV-PA coupling assessment to guide phenotype-specific management.
Background Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all global heart failure cases. Historically viewed as a left‐centric diastolic disorder, emerging evidence identifies right ventricular (RV) dysfunction and impaired ventriculo‐arterial (RV‐PA) coupling as central drivers of exercise intolerance, functional decline, and adverse clinical outcomes. Objectives This review synthesizes current evidence on the pathophysiological mechanisms, advanced diagnostic modalities, prognostic implications, and phenotype‐specific therapies for RV dysfunction in HFpEF, advocating for a transition to systematic biventricular evaluation. Methods A structured, PRISMA‐informed search of PubMed and Scopus (2015–2024) identified 74 eligible studies evaluating RV structure, function, and hemodynamics in HFpEF cohorts. Results RV dysfunction is prevalent in 19% to 33% of HFpEF patients and independently predicts all‐cause mortality and heart failure hospitalizations. Key pathophysiological drivers include post‐capillary pulmonary hypertension, impaired RV lusitropy, systemic inflammation, and inter‐ventricular dependence. Non‐invasive markers notably speckle‐tracking echocardiography, 4D‐flow cardiac magnetic resonance (CMR), and the TAPSE/PASP ratio enable early identification of subclinical RV‐PA uncoupling. While traditional heart failure therapies show limited efficacy, emerging options including SGLT2 inhibitors, interatrial shunt devices, GLP‐1 receptor agonists, and targeted pulmonary vasodilators demonstrate potential to preserve RV strain and restore hemodynamics across distinct clinical phenotypes. Conclusions RV dysfunction is a major prognostic marker in HFpEF. Routine inclusion of RV‐PA coupling indices in diagnostic and risk‐stratification algorithms is essential to guide precision‐based, phenotype‐guided management and improve clinical trajectories.
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Chamoun et al. (2026) conducted a review in Heart failure with preserved ejection fraction (HFpEF). Right ventricular dysfunction and ventriculo-arterial uncoupling vs. Normal right ventricular function in HFpEF was evaluated. Right ventricular dysfunction affects 19% to 33% of patients with HFpEF and independently predicts all-cause mortality and heart failure hospitalizations.
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