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Original Investigation
October 2018

Right Ventricular Function, Right Ventricular–Pulmonary Artery Coupling, and Heart Failure Risk in 4 US Communities: The Atherosclerosis Risk in Communities (ARIC) Study

Author Affiliations
  • 1Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Miyagi, Japan
  • 3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Department of Medicine, MacKay Medical College, Taipei, Taiwan
  • 5Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
  • 6Wake Forest University School of Medicine, Winston-Salem, North Carolina
JAMA Cardiol. 2018;3(10):939-948. doi:10.1001/jamacardio.2018.2454
Key Points

Question  Is subclinical right ventricular dysfunction associated with heart failure risk among elderly persons?

Findings  In this secondary analysis of a community-based cohort study, subclinical right ventricular dysfunction assessed by 3-dimensional echocardiography was present in nearly one-fifth of elderly persons, was associated with common heart failure risk factors, and increased in prevalence with more advanced American College of Cardiology/American Heart Association heart failure stage. When identified, asymptomatic right ventricular dysfunction identified individuals at heightened risk for the development of heart failure hospitalization or death independent of left ventricular ejection fraction and N-terminal pro b-type natriuretic.

Meaning  These findings suggest an important and underrecognized role of right ventricular dysfunction in the progression to heart failure and the potential utility of 3-dimensional echocardiography to more accurately assess right ventricular performance.


Importance  Limited data exist on the prevalence and prognostic importance of right ventricular (RV) dysfunction for heart failure (HF) in the general population.

Objective  To assess the prevalence of RV dysfunction and its association with HF and mortality in a community-based elderly cohort.

Design, Setting, and Participants  Cross-sectional and time-to-event analysis of participants in the Atherosclerosis Risks in the Community (ARIC), a multicenter, population-based cohort study at the fifth study visit from 2011 to 2013, with a median follow-up of 4.1 years. This study included 1004 elderly participants in the ARIC study attending the fifth study visit who underwent both 3-dimensional and 2-dimensional RV echocardiography. Three-dimensional echocardiography data were analyzed between September 15, 2015, and July 24, 2016.

Exposures  Right ventricular ejection fraction (RVEF), RV–pulmonary artery (PA) coupling defined by the RVEF/PA systolic pressure (PASP) ratio, and RV longitudinal strain by 3-dimensional echocardiography.

Main Outcomes and Measures  For cross-sectional analysis, the prevalence of RV dysfunction across ACCF/AHA HF stages (0; A, at elevated risk for HF but without structural heart disease or clinical HF; B, structural heart disease but without clinical HF; and C, prevalent HF). For time-to-event analysis, a composite of incident HF hospitalization or all-cause death among participants free of HF at visit 5.

Results  Of the 1004 participants, mean (SD) age was 76 (5) years, 385 were men (38%), and 121 were black (12%). Mean (SD) RVEF was 53% (8%). Right ventricular EF, RVEF/PASP, and RV longitudinal strain were each progressively lower across advancing HF stages. Using reference limits from stage 0 participants, RVEF was abnormal in 103 asymptomatic persons with stage A HF (15%) and 27 with stage B HF (24%). Among participants free of HF at baseline, lower RVEF and worse RV-PA coupling (ie, lower RVEF/PASP ratio) both were associated with incident HF or death independent of LVEF and N-terminal pro b-type natriuretic peptide (hazard ratio, 1.20; 95% CI, 1.02-1.42 per 5% decrease in RVEF; P = .03; hazard ratio, 1.65, 95% CI, 1.15-2.37 per 0.5 unit decrease in RVEF/PASP ratio; P = .007).

Conclusions and Relevance  Right ventricular function and RV-PA coupling declined progressively across American College of Cardiology Foundation/American Heart Association HF stages. Among persons free of HF, lower RVEF was associated with incident HF or death independent of LVEF or N-terminal pro b-type natriuretic peptide.