Deterioration in RV Structure and Function in HFpEF Patients

Study Questions:

What are the chronic changes in right ventricular (RV) structure and function (including the incidence of RV dysfunction [RVD]), what are its predictors, and does development of RVD predict outcome in patients with heart failure with preserved ejection fraction (HFpEF)?


The study cohort included 271 subjects with unequivocal HFpEF defined by either invasive hemodynamics or hospitalization for pulmonary edema and who also underwent serial echocardiographic evaluations >6 months apart. The authors examined clinical, structural, functional, and hemodynamic characteristics in this cohort. They assessed mortality rates using Kaplan–Meier curve analysis, and utilized univariable and multivariable Cox proportional hazards models to assess the independent prognostic power.


At initial examination, subjects with HFpEF were older aged (71 ± 9 years) and obese (body mass index [BMI] 32 ± 7 kg/m2) and had typical comorbidities such as hypertension, atrial fibrillation (AF), and coronary artery disease, as in the general population. Over a median period of 4.0 years (interquartile range, 2.1–6.1), there was a 10% decline in RV fractional area change and 21% increase in RV diastolic area (both p < 0.0001). These changes greatly exceeded corresponding changes in the left ventricle. The prevalence of tricuspid regurgitation increased by 45%. Of 238 patients with normal RV function at initial examination, 23% (n = 55) developed RVD during follow-up. Development of RVD was associated with both prevalent and incident AF, higher body weight, coronary disease, higher pulmonary artery and left ventricular filling pressures, and RV dilation. In an unadjusted Cox model, the development of RVD was associated with an 80% increased risk of death (hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.01-3.19; p = 0.04). Development of RVD remained significantly associated with mortality after adjustment for other established risk factors associated with mortality in HFpEF, including age, BMI, AF, EF, and E/e’ ratio (adjusted HR, 1.89; 95% CI, 1.01-3.44; p = 0.04).


The authors concluded that RV structure and function deteriorate to a greater extent over time when compared with changes in the left ventricle.


This is an important study because it suggests that the approach to HFpEF should include assessment of the right ventricle. Further studies are needed to validate these important findings and to determine whether sleep apnea is also a confounder in HFpEF, particularly in patients with accompanying RVD.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Hypertension, Sleep Apnea

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Body Mass Index, Coronary Artery Disease, Diastole, Dilatation, Echocardiography, Geriatrics, Heart Failure, Hypertension, Obesity, Primary Prevention, Pulmonary Edema, Risk Factors, Sleep Apnea Syndromes, Stroke Volume, Tricuspid Valve Insufficiency

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