Prognostic Role of Right Atrial Pressure in HF With Preserved Ejection Fraction

Recent data have provided new insight into the prognostic role played by right atrial (RA) hypertension in the complex pathophysiology of heart failure with preserved ejection fraction, suggesting the prognostic utility of estimated RA pressure (eRAP). These findings were published in the journal ESC Heart Failure.

A retrospective, observational study was conducted among patients who were admitted to either Gunma University Hospital in Maebashi, Japan, from January 2014 through June 2019, or to Hokkaido University Hospital in Sapporo, Japan, from January 2014 through December 2018. Recognizing the fact that right-sided filling pressure is elevated in some individuals with heart failure (HF) and HF with preserved ejection fraction (HFpEF), the researchers theorized that RAP would represent the cumulative burden of abnormalities in the left heart, the pulmonary vasculature, and the right heart.

A diagnosis of HFpEF was defined as the typical clinical symptoms of HF; an EF of 50% or more; and 1 or more of the following: directly measured pulmonary capillary wedge pressure of 15 mm Hg or higher, B-type natriuretic peptide levels of 200 pg/mL or more, ratio of early diastolic mitral inflow velocity to early diastolic mitral annular tissue velocity (E/e′) of 15 or greater, LA volume index of >34 mL/m2 or greater, or prior HF-related hospitalization.

The primary study endpoint was a composite of cardiovascular death or HF hospitalization, with the latter defined as dyspnea and pulmonary edema on chest x-ray that required the use of intravenous diuretic therapy.

A total of 399 patients with HFpEF who met inclusion criteria were enrolled in the study. All participants underwent echocardiography, during which estimated RAP (eRAP) was determined via inferior vena cava morphology and its respiratory change. Patients were divided according to eRAP (3 or ≥8 mm Hg). Participants with higher eRAP exhibited more severe abnormalities in left ventricular diastolic function, as well as in right heart structure and function, compared with those with normal eRAP. Cardiac death or hospitalization for HF was reported in 84 participants over a median follow-up of 19.0 months (IQR, 6.7-36.9 months).

Higher eRAP was significantly associated with an increased risk for the composite outcome compared with those with normal eRAP (adjusted hazard ratio, 2.20; 95% CI, 1.34-3.62; P =.002).

Patients were divided into 4 groups to evaluate the additive prognostic value of eRAP over E/e′ ratio. The 4 groups were based on combinations of eRAP and E/e′ ratio. Group 1 had an eRAP of 3 mm Hg and an E/e′ ratio of 15 or less. Group 2 had an eRAP of 3 mm Hg and an E/e′ ratio of 15 or more. Group 3 had an eRAP of 8 mm Hg or higher and an E/e′ ratio of 15 or less. Group 4 had an eRAP of 8 mm Hg or higher and an E/e′ ratio of 15 or less.

Event-free survival varied among the 4 groups, thus providing an incremental prognostic value of eRAP over E/e′ ratio. The classification and regression tree analysis showed that eRAP was the strongest predictor of outcome, which was followed by right ventricular dimension, E/e′ ratio, and estimated right ventricular systolic pressure. This, in turn, stratified the participants into 4 risk groups: low risk (event rates, 8.8%); intermediate risk (15.6%); high risk (29.9%-37.5%); and very high risk (72.2%).

A major limitation of the trial is the fact that the design is retrospective in nature, introducing possible selection and referral bias.

“Our data may provide new insights into the prognostic role of RA hypertension in the complex pathophysiology of HFpEF and suggest the prognostic utility of eRAP,” the study authors wrote. The evaluation of eRAP may further enhance risk stratification among patients with HFpEF and might be used to guide the use of treatments such as diuretics. Additional clinical trials are warranted, to establish whether eRAP-guided treatment strategy could improve outcomes among patients with HFpEF.

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies.  


Nagata R, Harada T, Omote K, et al. Right atrial pressure represents cumulative cardiac burden in heart failure with preserved ejection fraction. ESC Heart Fail. Published online February 15, 2022.  doi:10.1002/ehf2.13853