Right Heart Dysfunction in Heart Failure With Preserved Ejection Fraction

Study Questions:

What are the hemodynamic, clinical, and prognostic correlates of right ventricular dysfunction (RVD) in left ventricular (LV) diastolic heart failure?

Methods:

The study cohort was comprised of diastolic heart failure patients (n = 96) and controls (n = 46) who underwent right heart catheterization, echocardiographic assessment, and were regularly followed-up.

Results:

The investigators found that right and left heart filling pressures, pulmonary artery (PA) pressures, and right-sided chamber dimensions were higher in patients with diastolic heart failure compared with controls, whereas LV size and ejection fraction (EF) were similar in both groups. RV dysfunction (defined by RV fractional area change [FAC] <35%) was present in about one-third (33%) of diastolic heart failure patients, and was associated with more severe symptoms and greater comorbidity burden. RV function was impaired in diastolic heart failure compared with controls using both load-dependent (FAC: 40 ± 10 vs. 53 ± 7%, p < 0.0001) and load-independent indices (FAC adjusted to PA pressure, p = 0.003), with enhanced afterload-sensitivity compared with controls (steeper FAC vs. PA pressure relationship). In addition to hemodynamic load, RV dysfunction in diastolic heart failure patients was associated with male gender, atrial fibrillation, coronary disease, and greater ventricular interdependence. Over a median follow-up of 529 days (interquartile range, 143-1,066), 31% of diastolic heart failure patients died. Using Cox analysis, the investigators found that RV dysfunction was the strongest predictor of mortality (hazard ratio, 2.4; 95% confidence interval, 1.6-2.6; p < 0.0001).

Conclusions:

The authors concluded that right heart dysfunction is common in diastolic heart failure, and is caused by both RV contractile impairment and afterload mismatch from pulmonary hypertension.

Perspective:

This is an important study because it suggests that clinical trials targeting patients with diastolic heart failure need to keep in mind that there is accompanying right heart dysfunction. Prospective studies in diastolic heart failure patients will benefit from incorporating the important findings of this research in their study design. An important question that comes to mind regarding these findings is whether sleep apnea was a major confounder in this study cohort.

Clinical Topics: Heart Failure and Cardiomyopathies, Pulmonary Hypertension and Venous Thromboembolism, Acute Heart Failure, Chronic Heart Failure, Pulmonary Hypertension, Sleep Apnea

Keywords: Follow-Up Studies, Heart Failure, Diastolic, Cardiac Catheterization, Comorbidity, Coronary Disease, Pulmonary Artery, Cost of Illness, Sleep Apnea Syndromes, Ventricular Dysfunction, Right, Hemodynamics, Hypertension, Pulmonary, Confidence Intervals, Diastole


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