New Analysis Identifies Prognostic Indicators in Pulmonary Hypertension Secondary to HFrEF

Right ventricular end-systolic elastance to end-systolic arterial elastance coupling in excess of 0.68 was linked with preserved right ventricular function and better survival outcomes in patients with heart failure with reduced ejection fraction and secondary pulmonary hypertension.

A new report suggests that hemodynamic coupling of right ventricular contractility to increased afterload can serve as a prognostic tool to determine overall survival (OS) in patients with heart failure with reduced ejection fraction (HFrEF) and secondary pulmonary hypertension (PH).

The report, published in the journal ESC Heart Failure, could give physicians a better understanding of why some patients with HFREF and secondary PH survive and others do not.

“Failure of right ventricular (RV) function worsens outcomes in pulmonary hypertension (PH),” wrote corresponding author Thomas Rauwolf, PhD, of Magdeburg University, in Germany, and colleagues. “The adaptation of RV contractility to afterload, the RV-pulmonary artery (PA) coupling, is defined by the ratio of RV end-systolic to PA elastances (Ees/Ea).”

The investigators sought to use the pressure-volume loop (PV-L) technique to find a cutoff value for Eea/Ea that would be predictive of OS.

To achieve their objective, Rauwolf and colleagues analyzed data from the prospective Magdeburger Resynchronization Reponsder Trial, in which 112 patients underwent right and left heart echocardiography as well as a baseline PV-L and RV catheter measurement. Fifty patients within the cohort who did not have pre-implanted cardiac devices also underwent magnetic resonance imaging.

With a median follow-up of 4.7 years, the data suggested that the optimal cutoff of Ees/Ea is 0.68 (area under the curve: 0.697, P < .001).

“In patients with PH (n = 76, 68%) multivariate Cox regression demonstrated the independent prognostic value of RV-Ees/Ea in PH patients (hazard ratio 0.2, P < 0.038),” the authors wrote.

Specifically, the investigators found that patients with RV-Ees/Ea greater than the cutoff had comparable RV-Ees/Ea ratios to the 36 patients in the study who had HFREF without PH (0.9 vs 0.88, P = .39). RV size and function, as well as OS, were also similar between the two groups.

“In contrast, secondary PH with RV-PA coupling ratio Ees/Ea < 0.68 corresponded extremely close to cut-off values that define RV dilatation/remodelling (RV end-diastolic volume >160 mL, RV-mass/volume-ratio ≤0.37 g/mL) and dysfunction (right ventricular ejection fraction <38%, tricuspid annular plane systolic excursion <16 mm, fractional area change <42%, and stroke-volume/end-systolic volume ratio <0.59) and is associated with a dramatically increased short and medium-term all-cause mortality,” they wrote.

Magdeburg and colleagues noted a number of independent predictors associated with EEs/Ea less than 0.68 in patients with PH. They included:

  • A pre-existent dilated RV [end-diastolic volume >171 mL, odds ratio (OR) 0.96, P = .021]
  • High pulsatile load (PA compliance <2.3 mL/mmHg, OR 8.6, P = .003)
  • Advanced systolic left heart failure (left ventricular ejection fraction <30%, OR 1.23, P = .028).

The authors concluded that RV single-beat Ees/Ea appears closely linked with RV size and function and can give physicians a good indication of survival outcomes in patients with HFrEF and secondary PH. They added, however, that more study is needed to better understand how RV interacts with pulmonary vascular afterload and/or left ventricle/left atrium dysfunction.


Schmeißer A, Rauwolf T, Groscheck T, et al. Predictors and prognosis of right ventricular function in pulmonary hypertension due to heart failure with reduced ejection fraction [published online ahead of print, 2021 May 2]. ESC Heart Fail. 2021;10.1002/ehf2.13386. doi:10.1002/ehf2.13386

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