Right Ventricular Function and Prognosis in Stable Heart Failure Patients DANIEL MURNINKAS, MD, ANA C. ALBA, MD, DIEGO DELGADO, MD, MSc, MICHAEL MCDONALD, MD, FRCP(C), FILIO BILLIA, MD, PhD, FRCP(C), WAI S. CHAN, BSc, AND HEATHER J. ROSS, MD, MHSc, FRCP(C) Toronto, Ontario, Canada ABSTRACT Background: Right ventricular ejection fraction (RVEF) is a mortality predictor in heart failure (HF) patients. There are controversial results regarding the influence of RVEF on other important prognostic variables. The purpose of this study was to investigate the effect of RVEF on exercise parameters obtained during cardiopulmonary exercise testing (CPET), creatinine and B-type natriuretic peptide (BNP) levels, and a composite outcome of death, heart transplantation, or ventricular assist device implantation in ambulatory HF patients. Methods and Results: This retrospective cohort study included 246 ambulatory HF patients with CPETand RVEF evaluated with the use of first-pass radionuclide angiography. We analyzed the impact of RVEFon other prognostic factors with the use of multivariable linear regression. The mean age was 49 6 12 years. The mean peak VO 2 was 16.4 6 5.7 mL kg 1 min 1 , mean peak VE/VCO 2 34.1 6 9.1, mean creatinine 1.17 6 0.40 mg/dL, and median BNP 158 pg/mL (interquartile range 374 pg/mL). The mean left ventricular ejection fraction was 35 6 12% and the mean RVEF 38 6 10%. For every 10% decrease in RVEF, peak VO 2 decreased 0.97 mL kg 1 min 1 (P ! .05), creatinine increased 0.12 mg/dL (P ! .01), and log BNP increased 0.26 (P ! .05). Conclusions: We found an independent association between RVEF and prognostic markers in HF patients. Worsening RV function may exert its negative effect on prognosis through increasing congestion (elevated BNP), affecting renal blood flow (increased creatinine) and limiting left ventricular preload, thereby reducing exercise tolerance. (J Cardiac Fail 2014;20:343e349) Key Words: VO 2max , VE/VCO 2 , creatinine, BNP. The American Heart Association estimates that 5.8 million people in the United States have heart failure (HF), with w670,000 new cases each year and w277,000 HF deaths per year. 1 Heart failure is the most frequent cause of hospitalization in patients $65 years old. 1 In 2010, the estimated cost of HF in the United States was $39.2 billion, representing 1%e2% of all health care expenditures. 2 Although HF is a progressive condition, its course is often characterized by remissions and exacerbations. This makes it difficult to reliably predict prognosis. Nonetheless it is crucial to accurately estimate and refine prognosis to identify patients who would benefit from advanced thera- pies, such as cardiac transplantation and mechanical circu- latory support, or those who should be referred to palliative or hospice care. Moreover, prognostication is important to provide patients and families with accurate information about anticipated survival and the expected disease course. In addition, accurate prognostic evaluation may assist in the appropriate allocation of health resources. Many prog- nostic factors have been identified in HF. Among the most frequently used parameters are measures of functional class, parameters derived from cardiopulmonary exercise testing (CPET), B-type natriuretic peptide (BNP) levels, renal function, left ventricular ejection fraction (LVEF), and right ventricular ejection fraction (RVEF). From the Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. Manuscript received June 18, 2013; revised manuscript received January 21, 2014; revised manuscript accepted January 23, 2014. Reprint Requests: Daniel Murninkas, MD, Nahar Hayarden 65, 71703, Modiin, Israel. Tel: þ 972 0584 753375; Fax: þ 972 077453575. E-mail: danimur70@hotmail.com See page 349 for disclosure information. 1071-9164/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cardfail.2014.01.018 343 Journal of Cardiac Failure Vol. 20 No. 5 2014