Heart failure with preserved ejection fraction (HFpEF) is an important medical problem seen in around 50% of all heart failure (HF) patients, with poor clinical outcomes.1-3 In contrast to HF with reduced ejection fraction (HFrEF), options in treatment for patients with HFpEF are limited. More knowledge on the pathophysiology of HFpEF and exploration of its heterogeneous nature helps to develop future therapies. One of the vital features in HFpEF is left ventricular (LV) diastolic dysfunction and contractile dysfunction, inspite of the preservation of global ejection fraction (EF).4 Right ventricular dysfunction (RVD) is commonly seen in HFpEF, and the reported prevalence of RVD varies from 4% to 48% across two studies.5,6

Heart failure (HF) affects over 20 million people each year in both developed and developing countries around the world. The incidence of HF in developed countries is 2%.7 The risk of HF increases with age, affecting 6-10% of individuals aged 65 years and older. Women represent 50% of patients, which can be attributed to their longer life expectancy.7 The overall prevalence of HF is on the rise, due in part to new and advanced treatments for cardiac illnesses such as CAD, rheumatic heart disease, and arrhythmias, which help patients to live longer.

Heart failure (HF) is a significant public health care issue, which affects around 4.3 million people worldwide and is expected to reach 8 million by 2030, representing a 46% increase in prevalence.8

The lifetime risks of HF between the ages of 75 and 95 were found to be between 30% and 42% for white males, 20% and 29% for black men, 32% and 39% for white women, and 24% and 46% for black individuals. Individuals with higher BP and BMI at all ages had greater lifetime risks of HF. Despite a decrease in incidence due to preventative initiatives and improved treatment of acute coronary syndromes, the rise in HF prevalence can be attributed to the aging population and advancements in therapy for cardiac patients, resulting in a higher survival rate.9.

AIM AND OBJECTIVES

Aim:

To assess the prevalence of right ventricular systolic dysfunction in patients with HFpEF.

Objectives:

To study role of Right ventricular systolic dysfunction in prognosis, and mortality in patients of Heart failure with preserved ejection fraction(HFpEF). To compare all parameters between patients with and without RV systolic dysfunction.

The current study was conducted in the Department of Cardiology, Katuri Medical College, Andhra Pradesh, India.

Study period:

18 months- January 2023- June 2024

Type of study:

Prospective study.

Sample size calculation:

As per the survey, the prevalence of heart failure was 1.7% for patients aged 40–59 years, 4.9% for those aged 60–69 years, 7.0% for patients aged 70–79 years, and 10.1% for those aged≥80 years.10 Mean prevalence was 11.5%

N=Z2PQ/E2

N=sample size, P=Prevalence, Q=100-P E-Error: 5%, Z-Confidence levels: 85% N=85

The minimum sample size is 85

So we included 100 patients, considering 20% of incomplete data or dropouts.

INCLUSION CRITERIA:

Males and females aged above 18 years

Patients admitted with heart failure with EF above 50%

EXCLUSION CRITERIA:

Patients with HIV, tuberculosis, cancers, COPD. Pregnant and lactating women.

Significant left-sided valve disease. Patients with known cardiomyopathies.

Patients with congenital heart disease or pericardial disease

Methodology:

After receiving approval from the institutional ethics committee, the study was carried out. Informed consent was taken from every participant.

Data analysis: Data was processed using MS Excel 2023, with analysis performed through Microsoft Excel and the free version of EPI INFO (version 7.2.5.0). A p-value of less than 0.05 was taken as statistically significant.

Descriptive statistics like frequencies and percentages. Initially, the prevalence of RVD was assessed. Comparisons were made between patients with and without RVD. Chi-square test was used to find risk factors associated with RVD, T-test was used to compare numerical data between both groups.

Ethical aspects:

Approval for study was obtained from the Institutional Ethics Committee at Katuri Medical College, Guntur. Informed consent was taken from every participant.

Right ventricular dysfunction (RVD) was seen in 41% of the patients.

DEMOGRAPHY:

The average age of patients in both groups was similar — 58.5 years in the no-RVD group and 56.5 years in the RVD group — with no statistically significant difference (p = 0.30).

Gender distribution was nearly equal between the groups, and the occurrence of RVD did not differ significantly between males and females (p = 0.39).

The mean Body Mass Index (BMI) was not significantly different between groups, though patients with RVD had slightly more mean BMI (30.56 vs. 29.52; p = 0.07).

The presence of comorbidities like diabetes, hypertension, and others showed no significant variation between the RVD and no-RVD groups (p = 0.82)

DM alone was seen in 9 patients. HTN alone was seen in 15 patients. No comorbidities were seen in 63 patients.

Addictions seen in the two patient groups were similar. Overall, 5 patients had alcoholism, and 9 patients had smoking.

CARDIAC VARIABLES:

There is a significant difference in Tricuspid Annular Plane Systolic Excursion (TAPSE) between the two groups (Patients with and without RVD). It was more in patients with RVD.

There is a significant difference in fractional area change (FAC) between the two groups. Patients with and without RVD. It was more in patients with RVD.

There is a significant difference in SI between the two groups (Patients with and without RVD). It was more in patients with RVD.

There is a significant difference in mortality in between two groups(Patients with and without RVD). It was more in patients with RVD.

13 out of 100 patients expired in the current study. Among them, 9 had RVD.

TABLE 1: Comparison of cardiac variables between patients with and without RVD

Graph 1: TAPSE comparison between groups

Graph 2: S¹ comparison between groups

Table 2: Means of numerical parameter comparison between group

There is no significant difference in mean eGFR, HR, and Body surface area (BSA). between patients with and without RVD.

There is a significant difference in the mean duration of hospital stay between patients with and without RVD. It was more among patients with RVD.

There is a significant difference in mean ejection fraction (EF), Pulmonary Artery Systolic Pressure (PASP), deceleration time between patients with and without RVD. They were less among patients with RVD.

Graph 3: E/e¹ comparison between groups

41% of patients had RVD in this study among 100 heart failure patients included.

Prevalence of RVD in the study of Mohammed SF et al.11 was 20.6% among 562 HF patients included.

Mean age was 78.5 years in the study of Mohammed SF et al.11 There is significant difference in mean age between HF patients with and without RVD. There is no significant difference in gender in between RVD and non- RVD group, similar to the present study.

There is no significant difference in mean BMI between two groups of patients, similar to the present study. Mean BMI in patients with no RVD was 28.8 kg/m2 and mean BMI in RVD group patients was 28.2 kg/m2 in their study. HTN was seen among 85% patients with RVD in study done by Mohammed SF et al.11 Diabetes was seen in 30% patients with RVD. 58% were smokers, while in the current study, DM alone was seen in 9 patients. HTN alone was seen in 15 patients. No comorbidities were seen in 63 patients. Authors also reported that the median and mean 2D TAPSE were similar to values for M-mode TAPSE previously reported in healthy people

>70 yrs. TAPSE, FAC, MPAP, and PASP were associated with increased mortality. Patients with lower TAPSE had similar LV structure and LVEF but had lower stroke volume and cardiac index despite higher heart rate when compared to patients with higher TAPSE. Patients having moderate to severe RVD, smaller - LV dimensions, lower SBP and pulse pressure, higher prevalence of RV enlargement, and lower TAPSE were noted when compared to patients with mild RVD.

Benes J et al12 reported that RV size and the degree of dysfunction. With increasing RVD, patients were older males, had more severe LV dysfunction and enlarged LV cavity, more severe mitral and tricuspid regurgitation, lower plasma sodium and more BNP level, worse renal function and were often diabetic. RV global dysfunction score was associated with an adverse outcome even after adjusting the variables. Gorter et al.13 reported the following: Prevalence for RV dysfunction as

Mohammed SF et al.11 found that the difference in mean eGFR was not significant in both groups of patients similar to the current study.

Gorter et al.13 did a study on the Impact of Atrial Fibrillation in RV Dysfunction in HF with Preserved Ejection Fraction. There was a negative correlation between PASP and all parameters related to RV systolic function.

Benes J et al12 found that patients with lower TAPSE had similar LV structure and LVEF but had lower stroke volume and cardiac index in spite of more heart rate when compared to patients with higher TAPSE. 508 patients (60.8%) experienced an adverse outcome in the form of death, or urgent heart transplantation. 13 out of 100 patients expired in the current study. Among them, 9 had RVD.

Venner et al.14 studied RV dysfunction in idiopathic dilated cardiomyopathy. 136 patients were included in their study. Adverse cardiac event-free survival rates at 1 was 64 and 2 years was 55%, in group 1 In group 2, it was 87% and 79%, respectively. RV dysfunction was described as an independent predictor for MACE along with right atrial area and age.

Our study results showed a significant difference in mortality, mean duration of hospital stay, incidence of RV enlargement, ejection fraction, PASP, incidence of moderate- severe TR, mean deceleration time, mean SVR between two groups of patients. In this HFpEF cohort, a significant portion of patients showed signs of right ventricular systolic dysfunction, which was linked to more severe clinical and echocardiographic features and worse outcomes. The best method for evaluating RVD has yet to be determined. Findings from this study suggest that Heart failure with preserved ejection fraction may often be accompanied by RV systolic dysfunction, which indicates a worse prognosis, independent of comorbidities.

Sponsor: None Conflicts of interest: Nil.

1. Lam CS, Donal E, Kraigher-Krainer E, Vasan RS. Epidemiology and clinical course of heart failure with preserved ejection fraction. Eur J Heart Fail 2011; 13: 18–28.
2. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, RedfieldMM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006; 355: 251–259.
3. vanVeldhuisen DJ, Linssen GC, Jaarsma T, van Gilst WH, Hoes AW, Tijssen JG, Paulus WJ, Voors AA, Hillege HL. B-type natriuretic peptide and prognosis in heart failure patients with preserved and reduced ejection fraction. J Am CollCardiol 2013; 61: 1498–1506.
4. Borlaug BA, Lam   CS, Roger   VL, Rodeheffer   RJ, Redfield MM. Contractility and ventricular systolic stiffening in hypertensive heart disease insights into the pathogenesis of heart failure with preserved ejection fraction. J Am CollCardiol 2009; 54: 410–418.
5. Chatterjee NA, Steiner J, Lewis GD. It is time to look at heart failure with preserved   ejection   fraction   from   the   right side. Circulation 2014; 130: 2272–2277.
6. Zakeri R, Mohammed SF. Epidemiology of right ventricular dysfunction in heart failure with preserved ejection fraction. Curr Heart Fail Rep 2015; 12: 295–301.
7. Iglesias-Garriz I, Olalla-Gomez C, Garrote C, Lopez-Benito M, Martin J, Alonso D, Rodriguez MA. Contribution of right ventricular dysfunction to heart failure mortality: A meta-analysis. Rev Cardiovasc Med. 2012;13:e62–69. [PubMed] [Google Scholar]
8. Weiner BH, Alpert JS, Dalen JE, Ockene IS. Response of the right ventricle to exercise in patients with chronic heart disease. Am HeartJ. 1983;105:386–393. [PubMed] [Google Scholar]
9. Baker BJ, Wilen MM, Boyd CM, Dinh H, Franciosa JA. Relation of right ventricular ejection fraction to exercise capacity in chronic left ventricular failure. Am J Cardiol. 1984;54:596–599. [PubMed] [Google Scholar]
10. Bosch L, Lam CSP, Gong L, Chan SP, Sim D, Yeo D, Jaufeerally F, Leong KTG, Ong HY, Ng TP, Richards AM, Arslan F, Ling LH. Right ventricular dysfunction in left-sided heart failure with preserved versus reduced ejection fraction. Eur J Heart Fail. 2017 Dec;19(12):1664-1671. doi: 10.1002/ejhf.873. Epub 2017 Jun 8. PMID: 28597497.
11. Mohammed SF, Hussain I, AbouEzzeddine OF, Takahama H, Kwon SH, Forfia P, Roger VL, Redfield MM. Right ventricular function in heart failure with preserved ejection fraction: a community-based study. Circulation 2014; 130: 2310–2320
12. Benes J, Kotrc M, Wohlfahrt P, Kroupova K, Tupy M, Kautzner J, et al. Right ventricular global dysfunction score: a new concept of right ventricular function assessment in patients with heart failure with reduced ejection fraction (HFrEF). Front Cardiovasc Med [Internet]. 2023;10. Available from: http://dx.doi.org/10.3389/fcvm.2023.1194174
13. Gorter TM, Hoendermis ES, van Veldhuisen DJ, Voors AA, Lam CSP, Geelhoed B, et al. Right ventricular dysfunction in heart failure with preserved ejection fraction: a systematic review and meta‐analysis. Eur J Heart Fail [Internet]. 2016;18(12):1472–87. Available from: http://dx.doi.org/10.1002/ejhf.630
14. Venner C, Selton-Suty C, Huttin O, Erpelding ML, Aliot E, Juillière Y. Right ventricular dysfunction in patients with idiopathic dilated cardiomyopathy: Prognostic value and predictive factors. Arch Cardiovasc         2016      Apr;109(4):231-41.            doi: 10.1016/j.acvd.2015.10.006. Epub 2016 Jan 15. PMID: 26782624.