Cardiometabolic Risk Factors Associated With Right Ventricular Function and Compensation in Patients Referred for Echocardiography

Abstract

Background Pulmonary hypertension and right ventricular (RV) dysfunction are drivers of adverse outcomes; however, modifiable risk factors for RV dysfunction are not well described. We investigated the association between clinical markers of metabolic syndrome and echocardiographic RV function in a large referral population. Methods and Results Using electronic health record data, we performed a retrospective cohort study of patients aged ≥18 years referred for transthoracic echocardiography between 2010 and 2020 with RV systolic pressure (RVSP) or tricuspid annular plane systolic excursion (TAPSE) values. Pulmonary hypertension was defined by RVSP >33 mm Hg and RV dysfunction by TAPSE ≤1.8 cm. Our sample included 37 203 patients of whom 19 495 (52%) were women, 29 752 (83%) were White, with a median age of 63 years (interquartile range, 51-73). Median (interquartile range) RVSP was 30.0 mm Hg (24.0-38.7), and median TAPSE was 2.1 cm (1.7-2.4). Within our sample, 40% had recorded RVSP >33 mm Hg, and 32% with TAPSE <1.8 cm. Increase in RVSP from normal (<33 mm Hg) to mildly elevated (33-39 mm Hg) or elevated (>39 mm Hg) was associated with lower low-density lipoprotein and high-density lipoprotein, and higher hemoglobin A1c and body mass index (P<0.001). A decrease in TAPSE between groups of TAPSE >1.8 cm, TAPSE 1.5-1.8 cm, and TAPSE <1.5 cm was associated with increased triglyceride:high-density lipoprotein ratio and hemoglobin A1c, and decreased body mass index, low-density lipoprotein, high-density lipoprotein, and systolic blood pressure (P<0.001). Most associations between cardiometabolic predictors and RVSP and TAPSE were nonlinear with clear inflection points associated with higher pulmonary pressure and lower RV function. Conclusions Clinical measures of cardiometabolic function were highly associated with echocardiographic measures of right ventricular function and pressure.

Keywords: RVSP; TAPSE; echocardiography; metabolic syndrome; right ventricular dysfunction.

Figure 1. Model‐estimated relationship between metabolic syndrome components, right ventricular systolic function (RVSP), and right ventricular function.

A, Association between hemoglobin A1c and RVSP, tricuspid annular plane systolic excursion (TAPSE), TAPSE:RVSP ratio. B, Association between body mass index and RVSP, TAPSE, TAPSE:RVSP ratio. C, Association between LDL and RVSP, TAPSE, TAPSE:RVSP ratio. D, Association between HDL and RVSP, TAPSE, TAPSE:RVSP ratio. E, Association between triglyceride:HDL and RVSP, TAPSE, TAPSE:RVSP ratio. F, Association between systolic blood pressure and RVSP, TAPSE, TAPSE:RVSP ratio. Figure depicts RVSP, TAPSE, TAPSE:RVSP ratio and 5th to 95th percentile metabolic marker in models adjusted for age, sex, race, hypertension, COPD, Afib, CAD, medications, and heart failure. Solid lines represent model‐estimated mean outcome values, while shaded gray areas depict 95% CIs. Afib indicates atrial fibrillation; BMI, body mass index; BP, blood pressure; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; HbA1c, hemoglobin A1c; HDL, high‐density lipoprotein; and LDL, low‐density lipoprotein.

Figure 2. Relative contributions of each predictor within a model to outcome of interest.

Figure demonstrates impact of demographic, comorbidity, medication, and laboratory data on RVSP, TAPSE, and TAPSE:RVSP ratio in patients without heart failure (A) and with heart failure (B). A1c indicates hemoglobin A1c; ACEi, angiotensin‐converting enzyme inhibitor; Afib, atrial fibrillation; ARB, angiotensin receptor blocker; BB, beta‐blocker; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; HDL, high‐density lipoprotein; LDL, low‐density lipoprotein; MRA, mineralocorticoid receptor antagonist; RVSP, right ventricular systolic pressure; SBP, systolic blood pressure; and TAPSE, tricuspid annular plane systolic excursion.