Evolution and Prognostic Value of Right Ventricular to Pulmonary Artery Coupling During Guideline-Directed Medical Therapy Up-Titration

BACKGROUND: Up-titration of guideline-directed medical therapy (GDMT) is known to enhance left ventricular function in heart failure (HF) with reduced ejection fraction. However, data regarding its effect on right ventricular (RV) function remain sparse. We aimed to assess the impact of GDMT up-titration on the RV, especially RV to pulmonary artery coupling, and its prognostic value in these patients. METHODS: All consecutive patients (n=291) with left ventricular ejection fraction <50% followed for GDMT up-titration in a dedicated HF clinic in a tertiary center from January 2019 to June 2022 with an echocardiography at baseline (before up-titration) and at follow-up (end of up-titration) were included: RESULTS: The median age is 65 (55–74) years; 24% are female. Ischemic cardiomyopathy was the main cause of HF (47%), and left ventricular ejection fraction was 30% (22%–34%). After 2 years, 49 patients (17%) reached the primary end point (all-cause death or hospitalization for acute HF). RV size and function significantly improved after GDMT up-titration (all, P <0.001), including RV to pulmonary artery coupling assessed by tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (0.62 versus 0.81 mm/mm Hg; P <0.001). Tricuspid annular plane systolic excursion/systolic pulmonary artery pressure <0.65 mm/mm Hg at follow-up remained associated with the primary end point after adjustment with comorbidities (hazard ratio, 5.9 [95% CI, 2.8–12.1]; P <0.001), clinical and biological severity (hazard ratio, 6.4 [95% CI, 2.4–17.8]; P <0.001), and echocardiography (hazard ratio, 3.6 [95% CI, 1.6–8.4]; P =0.002). In addition, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure was associated with an incremental prognostic value (C-index improvement, P <0.01), over and above prognostic factors, including left ventricular ejection fraction. CONCLUSIONS: This study highlights the independent and incremental prognostic value of tricuspid annular plane systolic excursion/systolic pulmonary artery pressure in HF with reduced ejection fraction during GDMT up-titration, suggesting to also consider RV to pulmonary artery coupling with echocardiography as a treatment goal.