Right ventricular function in heart failure with preserved ejection fraction: a community-based study

Abstract

Background: The prevalence and clinical significance of right ventricular (RV) systolic dysfunction (RVD) in patients with heart failure and preserved ejection fraction (HFpEF) are not well characterized.

Methods and results: Consecutive, prospectively identified HFpEF (Framingham HF criteria, ejection fraction ≥50%) patients (n=562) from Olmsted County, Minnesota, underwent echocardiography at HF diagnosis and follow-up for cause-specific mortality and HF hospitalization. RV function was categorized by tertiles of tricuspid annular plane systolic excursion and by semiquantitative (normal, mild RVD, or moderate to severe RVD) 2-dimensional assessment. Whether RVD was defined by semiquantitative assessment or tricuspid annular plane systolic excursion ≤15 mm, HFpEF patients with RVD were more likely to have atrial fibrillation, pacemakers, and chronic diuretic therapy. At echocardiography, patients with RVD had slightly lower left ventricular ejection fraction, worse diastolic dysfunction, lower blood pressure and cardiac output, higher pulmonary artery systolic pressure, and more severe RV enlargement and tricuspid valve regurgitation. After adjustment for age, sex, pulmonary artery systolic pressure, and comorbidities, the presence of any RVD by semiquantitative assessment was associated with higher all-cause (hazard ratio=1.35; 95% confidence interval, 1.03-1.77; P=0.03) and cardiovascular (hazard ratio=1.85; 95% confidence interval, 1.20-2.80; P=0.006) mortality and higher first (hazard ratio=1.99; 95% confidence interval, 1.35-2.90; P=0.0006) and multiple (hazard ratio=1.81; 95% confidence interval, 1.18-2.78; P=0.007) HF hospitalization rates. RVD defined by tricuspid annular plane systolic excursion values showed similar but weaker associations with mortality and HF hospitalizations.

Conclusions: In the community, RVD is common in HFpEF patients, is associated with clinical and echocardiographic evidence of more advanced HF, and is predictive of poorer outcomes.

Keywords: diastole; heart failure; hypertension, pulmonary; ventricular dysfunction, right.

Figure 1

Distribution of tricuspid annular plane systolic excursion (TAPSE) in HFpEF patients (A; red, lowest; grey, middle and black, highest tertile). Insert (B) shows Tukey box and whisker plots of TAPSE values in patients with normal, mildly or moderate-severely depressed RV systolic function by semi-quantitative assessment. * p<0.05 vs normal RV function; † p<0.05 vs mildly depressed RV systolic function. Insert (C) shows the distribution of TAPSE in HFpEF and in an age and sex matched healthy control population without cardiovascular disease.

Figure 2

Kaplan Meier survival curves for HFpEF patients according to the level of right ventricular (RV) function or tricuspid regurgitation: In A, survival by tertiles of tricuspid annular plane systolic excursion (TAPSE); In B, survival according to RV function assessed by semiquantitative assessment (Normal, mild or moderate-severe (M-S) RV dysfunction (RVD)). In C, survival according to the severity of tricuspid regurgitation (None, Mild-Mod or Mod-Severe).

Figure 3

Kaplan Meier survival curves for HFpEF patients according to tertiles of pulmonary artery systolic pressure (PASP) among patients in highest (TAPSE≥20 mm; A), middle (TAPSE 16-19 mm; B) and lowest TAPSE tertile (TAPSE ≤ 15 mm; C),

Figure 4

Kaplan Meier survival curves for HFpEF patients according to tertiles of pulmonary artery systolic pressure (PASP) among patients with normal RV function by semi-quantitative assessment (A), or RV dysfunction (mild or moderate-severe) by semi-quantitative assessment (B).