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RV Strain for Prediction of Survival in HFrEF
Study Questions:
In patients with heart failure with reduced ejection fraction (HFrEF), what is the prognostic significance of right ventricular (RV) strain measures via speckle-tracking echocardiography for predicting overall and cardiovascular mortality, as compared to cardiac magnetic resonance (CMR) and conventional transthoracic echocardiogram (TTE) parameters?
Methods:
A total of 266 patients were enrolled, all with stable, chronic HFrEF who underwent CMR at a single institution between 2002 and 2015, with an available TTE within 40 days of CMR. Exclusion criteria were poor TTE image quality, severe chronic kidney disease, atrial fibrillation or flutter, at least moderate primary valve disease, secondary cardiomyopathies, and cardiotoxic chemotherapy. Primary and secondary endpoints were overall death and cardiovascular death. RV speckle-tracking strain measures included peak systolic global longitudinal strain (RVGLS) and peak systolic free wall longitudinal strain. CMR RV function parameters included RVEF, feature tracking (FT), fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE). TTE measures included all conventional measures as well as FAC and TAPSE.
Results:
Mean left ventricular EF was 23 ± 7%, age 60 ± 14 years, and 71% male gender. Heart failure was ischemic in 51% of patients and 56% were New York Heart Association (NYHA) class III or IV. After median follow-up of 4.7 years, 84 patients died of cardiovascular causes and 18 of noncardiac causes. Multivariate Cox regression analysis revealed multiple parameters (age, ischemic etiology, NYHA class) to be independent clinical predictors of overall mortality. CMR-RVEF, FT-RVGLS, FAC, and TAPSE provided additional prognostic value. The highest predictive value of all parameters for overall mortality was echo-derived RVGLS, with a hazard ratio of 2.5 (1.6-3.9).
Conclusions:
The authors concluded: 1) RV dysfunction assessed by either CMR or TTE predicts overall and cardiovascular death; and 2) echo-derived RVGLS provides strong additional prognostic value, superior to CMR-derived RV measures (RVEF, FT-RVGLS, TAPSE, and FAC) in predicting both overall and cardiovascular mortality.
Perspective:
This study suggests that a simple echocardiographic measurement, RVGLS, could be a powerful prognostic parameter for HFrEF patients. Limitations include retrospective design, enrollment at a single center with potential referral bias, and exclusion of patients with relevant comorbidities (chronic kidney disease, atrial fibrillation/flutter, significant valvular disease) and those with poor TTE image quality. Prospective studies in multiple centers will be needed to assess the applicability of these parameters in a real-world setting.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging
Keywords: Atrial Fibrillation, Atrial Flutter, Comorbidity, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Myocardial Ischemia, Renal Insufficiency, Chronic, Stroke Volume, Systole
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