CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 218 AFRICA Determinants of right ventricular systolic dysfunction among patients with left heart failure in a Ghanaian hospital Abdul-Subulr Yakubu, Eugene Amable, Alfred Doku, Francis Agyekum Abstract Background: The presence of right ventricular dysfunction affects outcomes in patients with left heart failure. We assessed the determinants of right ventricular systolic dysfunction (RVSD) among patients with left heart failure presenting to the Korle Bu Teaching Hospital of Ghana. Methods: Consecutive patients with left heart failure who were 18 years and above were prospectively enrolled and assessed for evidence of RVSD by measuring the tricuspid annular plane systolic excursion, the peak velocity of the tricuspid annulus in systole (RV S′), the two-dimensional right ventricular fractional area change (RV FAC) and the right ventricular myocardial performance index (RV MPI). Results: Two hundred and seventy participants were enrolled, of whom 75.2% had at least one abnormal index of right ventricular systolic function. The prevalence of RVSD was significantly higher among those with non-hypertensive heart failure (85.3 vs 66.0%, p < 0.001). The left ventricular outflow tract velocity–time integral (LVOT VTI) was strongly correlated with the RV FAC and an LVOT VTI < 9.8 cm predicted the presence of an RV FAC < 35% with a sensitivity of 81.5% and specificity of 81.9% [area under the curve 0.882; 95% confidence interval (CI): 0.838–0.926, p < 0.001]. Independent predictors of the presence of RVSD included a transmitral E/A > 2 [odds ratio (OR) = 4.684, 95% CI: 1.521–14.428, p = 0.007), left ventricular ejection fraction < 40% (OR = 4.205, 95% CI: 1.643–10.760, p = 0.003), pulmonary artery systolic pressure (PASP) ≥ 35 mmHg (OR = 2.434, 95% CI: 1.012– 5.852, p = 0.047) and systemic systolic blood pressure (SBP) < 140 mmHg (OR = 2.631, 95% CI: 1.152–6.011, p = 0.022). Conclusion: RVSD was common in these Ghanaian patients with left heart failure. Left ventricular function, SBP and PASP were independent predictors of the presence of RVSD. Pending further validation, the LVOT VTI may serve as a useful surrogate or screening tool for RVSD in these patients. Keywords: heart failure, right ventricular dysfunction, Ghana Submitted 13/7/22; accepted 23/8/22 Published online 29/9/22 Cardiovasc J Afr 2023; 34: 218–224 www.cvja.co.za DOI: 10.5830/CVJA-2022-051 Heart failure is a major public health problem in sub-Saharan Africa, where uncontrolled systemic hypertension remains the major cause.1,2 Heart failure patients with right ventricular (RV) dysfunction report poorer exercise tolerance and have a worse prognosis than patients with preserved RV function.3 The aetiology of RV dysfunction in left heart disease is varied. The function of the two ventricles are interdependent and left ventricular (LV) activity contributes substantially to the flow and pressure generated by the right ventricle during systole.4 The right ventricle may be involved as part of a global disease involving both ventricles or may suffer as a consequence of increased RV afterload in the context of pulmonary hypertension due to left heart failure.5 Historically, little attention has been paid to the study and interpretation of RV function.6 Diagnostic or therapeutic recommendations based on RV assessment are scant, mainly due to limited data on the determinants of RV function, mechanisms leading to its failure and its relationship to outcomes. The complex shape of the right ventricle presents inherent challenges in accurately assessing RV dimensions and functional parameters. Echocardiography is a widely available, inexpensive and validated tool for evaluation of the right ventricle.6 Risk-stratifying patients with heart failure, based on their RV function, may help identify those patients who are at a particularly high risk of adverse outcomes and help tailor their management. We assessed the clinical and echocardiographic determinants of RV systolic dysfunction (RVSD) in patients with left heart failure with a broad range of LV systolic function. Methods We conducted a cross-sectional study on consecutive patients with left heart failure (HF) presenting for echocardiography at the cardiology unit of the Department of Medicine and Therapeutics of Korle Bu Teaching Hospital (KBTH), Ghana, from January 2020 to June 2021. Inclusion criteria were age ≥ 18 years and a clinical diagnosis of left heart failure who fulfilled the Framingham criteria for the diagnosis of HF and who had satisfactory images on transthoracic echocardiography (TTE).7 Patients were excluded if there was another competing reason for their symptoms other than left HF or had no LV systolic or diastolic dysfunction or relevant structural left heart disease at echocardiography. Also excluded were patients with causes of elevated pulmonary pressures other than left heart disease, Department of Medicine, Tamale Teaching Hospital, Tamale, Ghana Abdul-Subulr Yakubu, MB ChB, subulr87@gmail.com University of Ghana Medical School, Accra, Ghana Eugene Amable, MD Alfred Doku, MD Francis Agyekum, MD Department of Medicine and Therapeutics, Korle Bu Teaching Hospital, Accra, Ghana Alfred Doku, MD Francis Agyekum, MD
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