Right Ventricular Strain Improves Cardiac MRI–based Prognostication in Heart Failure with Preserved Ejection Fraction

Background Right ventricular (RV) function is an independent predictor of clinical status and prognosis in multiple cardiovascular diseases; however, the prognostic value of RV strain in patients with heart failure with preserved ejection fraction (HFpEF) remains largely unknown. Purpose To determine the associations between RV strain variables derived from cardiac MRI feature tracking and adverse outcomes in patients with HFpEF. Materials and Methods This retrospective study included patients with HFpEF who underwent cardiac MRI from January 2010 to December 2018. The primary end point was all-cause mortality. The results were validated in a cohort of patients with HFpEF enrolled from January 2019 to June 2021. Cox regression analysis was performed to assess the associations between variables and clinical outcomes. Results The development cohort comprised 1019 patients (mean age, 56.9 years ± 12.3 [SD]; 710 men), and the validation cohort comprised 273 patients (mean age, 55.3 years ± 14.0; 191 men). During a median follow-up of 7.8 and 3.9 years, respectively, 103 patients in the development cohort and nine in the validation cohort died. Multivariable Cox regression analysis showed that RV global longitudinal and circumferential strain were independent predictors of all-cause mortality (adjusted hazard ratio per 1% increase, 1.07 [95% CI: 1.02, 1.12; P = .005] and 1.13 [95% CI: 1.05, 1.21; P < .001], respectively). The full model based on clinical, conventional imaging, and RV strain variables demonstrated the best discrimination performance in the development (C index = 0.794) and validation (C index = 0.782) cohorts. In a subgroup with T1 mapping data, RV global longitudinal and circumferential strain remained independent predictors after separate adjustment for native T1 value and extracellular volume fraction (all models, P < .05). Conclusion RV global longitudinal and circumferential strain derived from cardiac MRI were independent predictors of adverse outcomes in patients with HFpEF, providing greater prognostic value than traditional clinical and imaging-derived risk markers. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Murphy and Quinn in this issue.