Right Ventricular Function, Right Ventricular-Pulmonary Artery Coupling, and Heart Failure Risk in 4 US Communities: The Atherosclerosis Risk in Communities (ARIC) Study

Abstract

Importance: Limited data exist on the prevalence and prognostic importance of right ventricular (RV) dysfunction for heart failure (HF) in the general population.

Objective: To assess the prevalence of RV dysfunction and its association with HF and mortality in a community-based elderly cohort.

Design, setting, and participants: Cross-sectional and time-to-event analysis of participants in the Atherosclerosis Risks in the Community (ARIC), a multicenter, population-based cohort study at the fifth study visit from 2011 to 2013, with a median follow-up of 4.1 years. This study included 1004 elderly participants in the ARIC study attending the fifth study visit who underwent both 3-dimensional and 2-dimensional RV echocardiography. Three-dimensional echocardiography data were analyzed between September 15, 2015, and July 24, 2016.

Exposures: Right ventricular ejection fraction (RVEF), RV-pulmonary artery (PA) coupling defined by the RVEF/PA systolic pressure (PASP) ratio, and RV longitudinal strain by 3-dimensional echocardiography.

Main outcomes and measures: For cross-sectional analysis, the prevalence of RV dysfunction across ACCF/AHA HF stages (0; A, at elevated risk for HF but without structural heart disease or clinical HF; B, structural heart disease but without clinical HF; and C, prevalent HF). For time-to-event analysis, a composite of incident HF hospitalization or all-cause death among participants free of HF at visit 5.

Results: Of the 1004 participants, mean (SD) age was 76 (5) years, 385 were men (38%), and 121 were black (12%). Mean (SD) RVEF was 53% (8%). Right ventricular EF, RVEF/PASP, and RV longitudinal strain were each progressively lower across advancing HF stages. Using reference limits from stage 0 participants, RVEF was abnormal in 103 asymptomatic persons with stage A HF (15%) and 27 with stage B HF (24%). Among participants free of HF at baseline, lower RVEF and worse RV-PA coupling (ie, lower RVEF/PASP ratio) both were associated with incident HF or death independent of LVEF and N-terminal pro b-type natriuretic peptide (hazard ratio, 1.20; 95% CI, 1.02-1.42 per 5% decrease in RVEF; P = .03; hazard ratio, 1.65, 95% CI, 1.15-2.37 per 0.5 unit decrease in RVEF/PASP ratio; P = .007).

Conclusions and relevance: Right ventricular function and RV-PA coupling declined progressively across American College of Cardiology Foundation/American Heart Association HF stages. Among persons free of HF, lower RVEF was associated with incident HF or death independent of LVEF or N-terminal pro b-type natriuretic peptide.

Figure 1.. Representative Case From the Atherosclerosis Risk in Communities (ARIC) Study of Right Ventricular (RV) Quantification by 3-Dimensional (3-D) Echocardiography

Figure 2.. Mean Values of 3-Dimensional (3-D) Right Ventricular Ejection Fraction (RVEF), 3-D RV Longitudinal Strain (RVLS), and RVEF/Pulmonary Artery Systolic Pressure Ratio as a Measure of Right Ventricular–Pulmonary Artery (RV-PA) Coupling Across Heart Failure (HF) Stages

Tests for trend across HF stages were performed using multivariable linear regression models adjusting for age, sex, and race/ethnicity. ^aP <.05 for unadjusted and adjusted with age, sex and race/ethnicity (reference = stage 0). ^bP <.05 for unadjusted.

Figure 3.. Prevalence of Abnormal 3-Dimensional (3-D) Right Ventricular Ejection Fraction (RVEF), 3-D RV Longitudinal Strain (RVLS), and RVEF/Pulmonary Artery Systolic Pressure Ratio as a Measure of Right Ventricular–Pulmonary Artery (RV-PA) Coupling Across Heart Failure (HF) Stages

Abnormal limits were based on the 90th or 10th percentile limits derived from the stage 0 participants. Test for trend of the proportion with abnormal measures across HF stages was performed using multivariable logistic regression models adjusting for age, sex, and race/ethnicity. ^aP <.05 for unadjusted and adjusted with age, sex and race/ethnicity (reference = stage 0).

Figure 4.. Association of Better Values for Right Ventricular Ejection Fraction (RVEF) and RV–Pulmonary Artery (PA) Coupling With Lower Incidence of All-Cause Mortality or Incident Heart Failure Hospitalization

Solid line indicates incidence rate per 100 person-years at any given value of RVEF or RV-PA coupling. Dashed lines indicate the 95% confidence intervals for these incidence rates. Histograms show the population distribution of RVEF (A) and RV-PA coupling (B). The RV-PA coupling is assessed as the RVEF/PA systolic pressure ratio. After adjustment for age, sex, race/ethnicity, left ventricular ejection fraction, and N-terminal pro b-type natriuretic, the hazard ratio (HR) for all-cause mortality or incident heart failure per 5% decrease in RVEF was 1.20 (95% CI, 1.02-1.42; P = .03). The adjusted HR per 0.5 unit decrease in RVEF/PASP ratio was 1.58 (95% CI, 1.10-2.28; P = .01).