Right ventricular global constructive work as an echocardiographic predictor of worsening heart failure

Abstract Aims Worsening heart failure (WHF) is a pivotal event in the trajectory of chronic heart failure, yet early risk stratification remains challenging. Echocardiographic right ventricular myocardial work (RVMW), a pressure–strain–integrated index, may offer incremental prognostic value beyond conventional echocardiographic and biomarker-based markers. This study assessed whether right ventricular global constructive work (RVGCW), the principal component of RVMW, predicts WHF and cardiovascular mortality. Methods and results In this prospective study, we enrolled 215 ambulatory patients with chronic heart failure New York Heart Association Functional Class (II–IV), encompassing heart failure with reduced ejection fraction, heart failure with mildly reduced ejection fraction, and heart failure with preserved ejection fraction, all in sinus rhythm and receiving guideline-directed medical therapy. Comprehensive transthoracic echocardiography was performed using a GE Vivid E95 system with offline analysis (EchoPAC v204). Right ventricular myocardial work was quantified using a non-invasive pressure–strain loop methodology, and RVGCW was prespecified as the primary RVMW parameter of interest. Right ventricular global constructive work was derived from right ventricular pressure–strain loops integrating right ventricular (RV) global strain and estimated pulmonary pressures. Patients were followed for 24 months with scheduled 3-month assessments and additional visits for suspected WHF. The primary endpoint was composite WHF, defined as heart failure hospitalization or adjudicated subclinical WHF. Baseline RVGCW was significantly lower in patients who developed WHF compared with those who did not (607 ± 48 vs. 648 ± 52 mmHg%, P < 0.001). In multivariable Cox models adjusting for N-terminal pro-B-type natriuretic peptide, left atrial reservoir strain, left ventricular global longitudinal strain, left atrial volume index, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure, and RV strain, RVGCW remained independently associated with WHF (hazard ratio 0.978, 95% confidence interval 0.973–0.998, P = 0.014). In receiver operating characteristic analysis, a cohort-derived RVGCW threshold demonstrated high discrimination for WHF (area under the curve 0.90). Conclusion Echocardiographic RVGCW is a strong, independent predictor of WHF and provides substantial incremental prognostic information beyond traditional markers; its association with cardiovascular mortality was exploratory.