Background:

Right heart function is known to be an independent risk factor for early mortality in patients with acute and chronic heart failure (HF). Additionally, it is established that chronic HF is associated with circulating inflammatory cytokines that might help in predicting clinical outcomes. Even though the underlying mechanism remains largely unknown, the majority of trials targeting inflammation in HF have reported neutral results. In addition to inflammation potentially caused by intestinal transmission, metabolic load-induced pro inflammatory signaling might play a role in patients with obesity, diabetes, and renal insufficiency.

Objectives :

We performed a single-center retrospective cohort analysis of patients with chronic heart failure that presented in our specialized heart failure outpatient clinic regarding all-cause mortality in relation to right ventricular (RV) function and systemic inflammation.

Methods:

A total of 612 patients with heart failure across the whole spectrum of left ventricular ejection fraction (LVEF) that presented between January 2015 and June 2017 were analyzed. All patients underwent laboratory testing, transthoracic echocardiography (TTE) and cardiopulmonary exercise testing (CPET) by upright bicycle ergometry. We stratified patients according to RV function and CRP levels. The cut-off for CRP was predefined at 5 mg/l. RV dysfunction was present, when the tricuspid annular plain systolic excursion (TAPSE) was below 16mm, basal right ventricular end diastolic diameter (RVEDD) was above 41mm or right ventricular outflow tract diameter was above 30mm. All patients were followed up by phone or by hospital records if available. All patients signed an informed consent. The primary end-point of all-cause mortality was assessed.

Results:

For the primary analysis, 612 patients (mean age 59,87 ± 13,831 years, 71,09% male) were included. According to LVEF at enrollment 248 (or 40,52%) patients had preserved LVEF (HFpEF), 82 (or 13,07%) had mid-range LVEF (HFmrEF) and 282 (or 46,08%) had reduced LVEF (HFrEF). HF etiology was in 27% ischemic. Mean BNP values were 514.19 ± 827.178 pg/l. Patients were followed up for a median of 1166 days. Over this period, the primary end-point occurred in 17.65% of patients. Patients with elevated CRP and RV-dysfunction showed a worse survival according to the Kaplan-Meier-Estimate with a significant difference (Log Rank: Chi²: 20.015, p < 0,001) compared to patients with only RV dysfunction or only increased CRP values.

In Cox regression univariate analysis, RV dysfunction categorical variable was predictive of the primary endpoint (HR 2,09; CI: 1,409-3,099; p<0,001). The CRP categorical variable also showed significant results (HR 1,742; CI: 1,180-2,572, p<0,001).

Conclusion:

A combined evaluation of systemic inflammation and right ventricular dysfunction is useful in predicting long-term outcomes of patients with chronic HF. Patients with both risk factors show a significant worse prognosis than patients with only signs of inflammation or RV dysfunction.