Potential Link Found Between Heart Failure Prognosis, Changes in RVFAC

Following their hospital discharge, patients with decompensated heart failure (HF) were shown to have a worse prognosis for adverse cardiac events and all-cause mortality in light of deleterious changes to their right ventricular fractional area change (RVFAC), according to new study findings in Circulation Journal.

“It is still unclear whether changes in right ventricular function are associated with prognosis in HF patients,” the authors wrote. “In the present study, we focused on changes in RVFAC, and aimed to clarify the clinical characteristics and prognosis of HF patients with worsened RVFAC.”

The prospective observational study investigated outcomes among 480 patients hospitalized between February 2010 and October 2018 at Fukushima Medical University Hospital in Japan whose RVFAC—above 35%, 25% to 35%, and below 25%—was evaluated via echocardiography at hospital discharge and in the outpatient setting. Following those 2 evaluations and the changes seen among the patients, they were classified into 4 categories of RVFAC change.

Overall, most patients (n = 235) had preserved and unchanged RVFAC, and this was followed by reduced and improved RVFAC (n = 106), preserved or reduced/worsened RVFAC (n = 92), and reduced and unchanged RVFAC (n = 47). The mean interval between the 2 evaluations was 7 (range, 3-10) months, and the mean (SD) patient age was 62.2 (15.5) years. Most (62.7%) were males.

Patients were followed from the day of their second examination through March 2020, during which time they were watched for cardiac events or all-cause death; the mean follow-up was 1365 (range, 7-3640) days. If there were 2 or more cardiac events, only the first was considered in the authors’ analysis.

Mean body mass indices ranged from 23.0 (4.0) kg.m² in the preserved/unchanged group to 23.9 (3.8) kg/m² in the preserved or reduced/worsened cohort. The most common comorbidity was dyslipidemia in 75.7%, 68.9%, 76.1%, and 72.3% of the preserved/unchanged, reduced/improved, preserved or reduced/worsened, and reduced/unchanged classifications. β blockers were the most common medications in 80% and 80.4% of the preserved/unchanged preserved or reduced/worsened groups, respectively, and diuretics in 75.5% and 76.6% of the reduced/improved and reduced/unchanged groups, respectively.

The primary form of HF seen among the 4 RVFAC classifications was HF with preserved ejection fraction (P = .516). Hypertension was most common in the preserved/unchanged group and chronic kidney disease (CKD) in the preserved or reduced/worsened group (P = .006 and .049, respectively).

“There was a negative correlation between changes in RVFAC with changes in right ventricular end-systolic volume index (r = −0.54; P < .01), but not with changes in right ventricular end-diastolic volume index (r = –0.48; P = .33),” the authors wrote.

There were 144 hospitalizations during the follow-up period, and during these, 18 patients died. Outside of the hospital, there were 147 all-cause mortalities and half (74) were cardiac related.

A Kaplan-Meier analysis linked RVFAC changes between the first and second examinations to the cardiac event rate (P < .001) and all-cause mortality (P = .010), both of which were highest in the reduced/worsened RVFAC group; a multivariable logistic regression analysis demonstrated that CKD and anemia predicted outcomes in the preserved or reduced/worsened RVFAC group; and a multivariable Cox proportional hazard analysis showed that preserved or reduced/worsened RVFAC was associated with a 133% greater risk of a cardiac event (HR, 2.33; 95% CI, 1.58-3.43) vs preserved/unchanged RVFAC and a 119% greater risk of all-cause mortality (HR, 2.19; 95% CI, 1.28-3.76) vs reduced/improved RVFAC.

“Our results demonstrated that the worsening of RV function, rather than RV dysfunction at baseline, may have prognostic implications,” the authors concluded. “Furthermore, the present study revealed factors associated with changes in RVFAC and their effect on prognosis. In general, the right ventricle is more adapted to volume overload than pressure overload, but recent studies have shown that prolonged volume overload may develop RV dysfunction.”

The authors emphasized that their findings should be considered preliminary and confirmed in larger studies that encompass more than 2 measures of RVFAC, as well as tricuspid annular plane systolic excursion, RV strain, and TV s’.

Reference

Sugawara Y, Yoshihisa A, Takeishi R, et al. Prognostic effects of changes in right ventricular fractional area change in patients with heart failure. Circ J. Published online July 1, 2022. doi:10.1253/circj.CJ-22-0212