CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 220 AFRICA HFrEF was present in 146 of the participants (54.1%) while 31 (11.5%) and 93 (34.4%) had HFmrEF and HFpEF, respectively. Table 2 summarises the echocardiographic characteristics based on the presence or absence of RVSD. LVEF was significantly lower in those with RVSD. Measures of diastolic function (mitral and tricuspid E/A and E/e′ ratios and deceleration time) were significantly worse in those with RVSD. Pulmonary hypertension, defined as a PASP > 35 mmHg, was present in 84.6% of those with RVSD and 48.9% of those without RVSD (p < 0.001). Overall, 203 (75.2%) of the participants had at least one abnormal index of RV systolic function. Abnormal TAPSE was present in 53.3% of participants while abnormal RV S′ and RV FAC were present in 40.0 and 43.1% of participants, respectively (Fig. 1). RV global function, as assessed by the RV MPI, was abnormal (> 0.55) in 65.2% of the participants. Seventy-six (28.1%) had abnormal values for all the indices of RVSD. All the measures of RV systolic function were significantly worse at lower LVEF. Table 3 summarises the likely HF aetiology of the study participants. Hypertensive heart disease was the predominant cause of HF, responsible for 52.2% of cases. Among participants with dilated cardiomyopathy (DCM), no obvious cause was found in 83.0% of the cases, while 7.5% were alcohol related. Peripartum cardiomyopathy was diagnosed in 5.9% of the study participants. Rheumatic mitral or aortic valve disease was the commonest primary valvular cause of HF, accounting for 62.5% of the cases of primary valvular heart disease causing left HF. The prevalence of RVSD in those with non-hypertensive HF was significantly higher than in those with hypertensive HF (85.3 vs 66.0%, p < 0.001). The RV MPI was worse in those with an ischaemic aetiology of their HF (p = 0.041). However, the values of TAPSE, RV S′ and RV FAC did not differ based on ischaemic versus non-ischaemic aetiology of the HF. Table 1. Clinical characteristics of participants according to RV systolic function Variable Total (n = 270) (100%) No RVSD (n = 67) (24.8%) RVSD (n = 203) (75.2%) p-value Age, years 57.0 ± 15.7 59.5 ± 14.5 56.2 ± 16.0 0.126 Gender (female), n (%) 132 (48.9) 33 (49.3) 99 (48.8) 0.945 Diabetes mellitus, n (%) 59 (21.9) 14 (20.9) 45 (22.2) 0.827 Hypertension, n (%) 191 (70.7) 56 (83.6) 135 (66.5) 0.008* Dyslipidaemia, n (%) 60 (22.2) 12 (17.9) 48 (23.6) 0.328 Ever smoker, n (%) 29 (10.7) 9 (13.4) 20 (9.9) 0.412 Alcohol use, n (%) 84 (31.1) 24 (35.8) 60 (29.6) 0.337 NYHA class, n (%) < 0.001* I 10 (3.7) 5 (7.5) 5 (2.5) II 76 (28.1) 35 (52.2) 41 (20.2) III 83 (30.7) 17 (25.4) 66 (32.5) IV 101 (37.4%) 10 (14.9%) 91 (44.8) SBP (mmHg) 131.0 ± 30.4 149 ± 36 125 ± 26 < 0.001* DBP (mmHg) 83.0 ± 20.5 89 ± 24 81 ± 19 0.004* Weight, kg 72.0 (66.0–83.0)73.0 (68.0–80.0)71.0 (66.0–83.0) 0.739 Height, cm 168.0 (165.0–170.0) 168.0 (165.0–170.0) 168.0 (165.0–170.0) 0.556 BMI, kg/m2 26.39 ± 4.41 26.8 ± 5.0 26.3 ± 4.2 0.361 BSA, m2 1.85 ± 0.17 1.87 ± 0.17 1.85 ± 0.17 0.447 Treatment, n (%) ACEI 73 (27.0) 21 (31.3) 52 (25.6) 0.360 ARB 43 (15.9) 9 (13.4) 34 (16.7) 0.520 ARNI 11 (4.1) 1 (1.5) 10 (4.9) 0.302 Beta-blocker 96 (35.6) 24 (35.8) 72 (35.5) 0.958 MRA 53 (19.6) 4 (6.0) 49 (24.1) 0.001* Loop diuretics 184 (68.1) 38 (56.7) 146 (71.9) 0.021* ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor–neprilysin inhibitor; BMI, body mass index; BSA, body surface area; DBP, diastolic blood pressure; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart Association functional class; SBP, systolic blood pressure. All values are presented as mean ± SD, n (%) or median (interquartile range). *p-value is statistically significant. Table 2. Echocardiographic characteristics of the participants with and without RVSD Variable No RVSD (n = 67) (24.8%) RVSD (n = 203) (75.2%) p-value Left atrial area, cm2 24.5 ± 6.2 26.0 ± 6.7 0.106 Right atrial area, cm2 17.7 ± 6.1 22.8 ± 8.5 < 0.001* Left atrial volume index, ml/m2 45.4 ± 17.5 53.4 ± 25.7 0.020* LV end-diastolic diameter, cm 5.3 ± 1.0 5.8 ± 1.2 0.001* LV end-systolic diameter, cm 3.8 ± 1.1 4.7 ± 1.4 < 0.001* LV mass index, g/m2 138.0 ± 49.6 137.9 ± 51.5 0.997 Relative wall thickness 0.48 ± 0.17 0.41 ± 0.22 0.007* LV end-diastolic volume, ml 119.4 ± 57.7 157.7 ± 78.5 < 0.001* LV end-systolic volume, ml 62.9 ± 48.7 107.9 ± 69.3 < 0.001* LV ejection fraction (%) 52.7 ± 16.3 36.0 ± 18.2 < 0.001* LVOT VTI, cm 16.7 ± 6.4 10.8 ± 5.7 < 0.001* RV basal diameter, cm 4.0 ± 0.8 4.5 ± 1.0 0.002* RV mid-diameter, cm ± 0.5 3.2 ± 0.9 0.001* RV longitudinal diameter, cm 6.8 ± 1.2 7.3 ± 1.4 0.011* RVOT diameter, cm 2.8 ± 0.5 3.2 ± 0.7 0.001* RV end-diastolic area, cm2 17.7 ± 6.2 21.7 ± 8.6 0.002* RV end-systolic area, cm2 9.0 ± 3.7 14.6 ± 7.4 < 0.001* MV E/A ratio 1.2 ± 0.8 2.2 ± 1.1 < 0.001* MV E/e′ ratio 14.1 ± 6.8 18.6 ± 7.7 < 0.001* MV DT, ms 187 ± 73 126 ± 53 < 0.001* TV E/A ratio 1.0 ± 0.7 1.7 ± 0.9 < 0.001* TV E/e′ ratio 7.5 ± 4.6 10.6 ± 6.2 0.015* TV DT, ms 207 ± 66 152 ± 56 < 0.001* PASP, mmHg 37.5 ± 14.3 49.0 ± 15.9 < 0.001* DT, deceleration time; E/A, early to late diastolic ventricular filling velocity ratio; E/e′, early diastolic filling velocity to early diastolic annular velocity ratio; RV FAC, right ventricular fractional area change; LVOT VTI, left ventricular outflow tract velocity–time integral; RV MPI, right ventricular myocardial performance index; MV, mitral valve; PASP, pulmonary artery systolic pressure; RVOT, right ventricular outflow tract; RVSD, right ventricular systolic dysfunction; TAPSE, tricuspid annular plane systolic excursion; TV, tricuspid valve. All values are presented as mean ± SD. *p-value is statistically significant. HFrEF HFmrEF HFpEF TOTAL TAPSE 75.3 41.9 22.6 53.3 RV S′ 60.3 29.0 11.8 40.0 RV FAC 62.1 39.1 15.2 43.1 RV MPI 76.7 55.0 50.0 65.2 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 –.0 Prevalence (%) 75.3 76.7 60.3 62.1 41.9 29.0 39.1 55.0 26.2 11.8 15.2 50.0 53.4 40.0 43.1 65.2 TAPSE RV S′ RV FAC RV MPI Fig. 1. Prevalence of abnormal TAPSE, RV S′, RV FAC and RV MPI stratified by LVEF.
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