Prognostic Value of Biventricular Strain in Risk Stratifying in Patients With Acute Heart Failure

Jae-Hyeong Park, Jin Joo Park, Jun-Bean Park, Goo-Yeong Cho, Jae-Hyeong Park, Jin Joo Park, Jun-Bean Park, Goo-Yeong Cho

Abstract

Background Few studies have shown that right ventricular ( RV ) function is independently related to adverse events regardless of left ventricular ( LV ) function in heart failure. We evaluated the prognostic value of global longitudinal strain ( GLS ) of both ventricles in patients with acute heart failure. Methods and Results We measured biventricular strains in 1824 randomly selected patients (973 men, aged 70±14 years) from a strain registry. A total of 799 patients (43.8%) died during the median follow-up duration of 31.7 months. In univariate analysis, LVGLS and RVGLS were significantly associated with all-cause mortality. We classified them into 4 strain groups according to LVGLS (≥9%) and RVGLS (≥12%). On Cox proportional hazards analysis, group 4 (<9% LVGLS and <12% RVGLS ) had the worst prognosis, with a hazard ratio ( HR ) of 1.755 (95% confidence interval [ CI ], 1.473-2.091; P<0.001) compared with that of group 1 (≥9% LVGLS and ≥12% RVGLS ). After multivariate analysis, both LVGLS (per 1% decrease; HR : 1.057; 95% CI , 1.029-1.086; P<0.001) and RVGLS (per 1% decrease; HR : 1.022; 95% CI , 1.004-1.040; P=0.014) were also significant. The HR of RVGLS <12% was higher in patients without pulmonary hypertension (assessed by maximal tricuspid regurgitation ≤2.8 m/s) after the adjustment of LVGLS ( HR : 1.40 [95% CI , 1.11-1.77] versus 1.07 [95% CI , 0.88-1.30] with pulmonary hypertension; interaction, P=0.043). Conclusions In the patients with acute heart failure, RVGLS was significantly associated with all-cause mortality regardless of LVGLS , and those with decreased biventricular GLS showed the worst prognosis. The predictive power of RVGLS was more prominent in the absence of pulmonary hypertension.

Keywords: heart failure; prognosis; strain echocardiography.

Figures

Figure 1
Figure 1
Scatter diagram according to left ventricular global longitudinal strain (LVGLS) and right ventricular global longitudinal strain (RVGLS). LVGLS shows significant correlation with RVGLS (r=0.494, P<0.001). Study patients are divided into 4 groups according to LVGLS of 9% and RVGLS of 12%.
Figure 2
Figure 2
All‐cause survival curves by Kaplan–Meier analysis. Patients with impaired left ventricular global longitudinal strain (LVGLS, <9%) and impaired right ventricular global longitudinal strain (RVGLS, <12%) have the poorest all‐cause survival than other groups (P<0.001).
Figure 3
Figure 3
Survival curves according to the right ventricular global longitudinal strain (RVGLS) of 12%. In patients without pulmonary artery hypertension (left), RVGLS has statistical significance even after the adjustment of left ventricular global longitudinal strain (LVGLS). However, RVGLS fails to have statistical significance after the adjustment of LVGLS (right). Dotted line: unadjusted survival; solid line: adjusted survival for LVGLS. CI indicates confidence interval; HR, hazard ratio; LV, left ventricular; RV, right ventricular.
Figure 4
Figure 4
Hazard ratio (HR) of right ventricular global longitudinal strain (RVGLS) of PH). CI indicates confidence interval; HR, hazard ratio.

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