BackgroundThe pulmonary artery (PA) distends as pressure increases.HypothesisThe ratio of PA to aortic (Ao) diameter may be an indicator of pulmonary hypertension and consequently carry prognostic information in patients with chronic heart failure (HF).MethodsPatients with chronic HF and control subjects undergoing cardiac magnetic resonance imaging were evaluated. The main PA diameter and the transverse axial Ao diameter at the level of bifurcation of the main PA were measured. The maximum diameter of both vessels was measured throughout the cardiac cycle and the PA/Ao ratio was calculated.ResultsA total of 384 patients (mean age, 69 years; mean left ventricular ejection fraction, 40%; median NT‐proBNP, 1010 ng/L [interquartile range, 448–2262 ng/L]) and 38 controls were included. Controls and patients with chronic HF had similar maximum Ao and PA diameters and PA/Ao ratio. During a median follow‐up of 1759 days (interquartile range, 998–2269 days), 181 patients with HF were hospitalized for HF or died. Neither PA diameter nor PA/Ao ratio predicted outcome in univariable analysis. In a multivariable model, only age and NT‐proBNP were independent predictors of adverse events.ConclusionsThe PA/Ao ratio is not a useful method to stratify prognosis in patients with HF.

Introduction Prolonged QRS duration is an important marker of adverse cardiovascular outcome for patients with heart failure (HF), but the contribution of QRS morphology is unclear. This is important, as QRS duration and morphology are advocated as criteria for the selection of patients for cardiac resynchronisation therapy. Methods Out-patients attending a community HF service between 2000 and 2010 that also underwent cardiac MRI were enrolled. HF was defined as the presence of relevant symptoms and signs and objective evidence of cardiac dysfunction: either a left ventricular ejection fraction (LVEF) <50% or a raised amino-terminal pro-brain natriuretic peptide (NT-proBNP) >125 pg/ml. QRS duration >120 ms was grouped as left (LBBB), right bundle branch block (RBBB) or indeterminate ventricular conduction delay (IVCD) depending on ECG findings. Results Of 878 patients enrolled, 176 (20%) had QRS 120–150 ms and 129 (15%) had QRS >150 ms. The prevalence of LBBB, RBBB and IVCD amongst patients with QRS 120–150 ms was 52%, 24% and 24% respectively and amongst patients with QRS >150 ms was 81%, 16%, 3%. Compared to patients with LBBB, those with RBBB had more evidence of congestion, a higher prevalence of atrial fibrillation (11% vs 25%; p<0.005), and higher plasma NTproBNP (1158 (582–2194) vs 2013 (668–3763)ng/l; p=0.015). LVEF was similar amongst patients with RBBB, LBBB and IVCD, but patients with RBBB had a more dilated left atrium, a lower right ventricular (RV) ejection fraction and greater RV mass. Patients with IVCD had similar characteristics to patients with RBBB but a shorter QRS duration. During a median follow up of 1302 days (IQ range 742–2253), 271 patients died. Compared with patients who had QRS <120 ms, RBBB (HR 1.7; 95% CI 1.1 to 2.5, p=0.011) and IVCD (HR 1.7; 95% CI 1.1 to 2.6, p=0.016) were associated with an adverse outcome, but LBBB was not. Restricting analysis only to patients with LVEF <35%, compared to patients who had QRS <120 ms, only QRS 120–150 ms was associated with a higher mortality (HR 1.62, 95% CI 0.99 to 2.65, p=0.05). This may reflect high adoption rates of cardiac resynchronisation in patients with QRS >150 ms. Overall, in multivariable Cox regression models, QRS duration or morphology were not independently associated with an adverse outcome. Conclusions In patients with chronic HF with or without a reduced LVEF and QRS>120 ms, RBBB morphology on ECG identifies patients with more severe bi-ventricular dysfunction on cardiac MRI who also have an adverse outcome. Although not independently significant in multi-variable models it is a simple method of identifying patients with other adverse prognostic features.

Introduction: Prolonged QRS duration has been associated with an adverse outcome in patients with heart failure (HF), but the contribution of QRS morphology is unclear. Methods: Out-patients attending a community HF service between 2000 and 2010 who had cardiac magnetic resonance imaging (CMRI) were included in this analysis. HF was defined as the presence of symptoms or signs, associated with objective evidence of cardiac dysfunction: either a left ventricular ejection fraction (LVEF) <50% or a raised amino-terminal pro-brain natriuretic peptide (NT-proBNP) >125 pg/ml. QRS duration >120 msec was grouped as left (LBBB), right bundle branch block (RBBB) or indeterminate ventricular conduction delay (IVCD) by ECG criteria. Results: Heart failure was confirmed in 878 patients, and 323 had QRS>120 msec. Comparing patients with LBBB, those with RBBB had a lower right ventricular ejection fraction (RVEF – RBBB: 47 (37-57), IVCD: 48 (42-56), LBBB: 51 (42-60) %; p=0.041), greater RV mass (RBBB: 53 (41-73), IVCD: 49 (41-61), LBBB: 45 (36-56) g; p<0.001), higher plasma NTproBNP (RBBB: 2013 (668-3763), IVCD:1044 (416-2737), LBBB:1158 (582-2194) pg/ml, p=0.046), more signs of peripheral congestion and higher prevalence of atrial fibrillation. During a median follow up of 1302 days (IQ range 742 – 2253), 271 patients died. Compared with patients who had QRS <120 msec, RBBB (HR 1.7; 95% CI: 1.1-2.5, p= 0.011) and indeterminate morphologies (HR 1.7; 95% CI: 1.1-2.6, p= 0.016) were associated with an adverse outcome, but LBBB was not. In a multivariable Cox regression model including MRI data, neither QRS duration nor morphology were independently associated with an adverse outcome. Conclusions: In patients with chronic HF with or without a reduced LVEF and QRS> 120 msec, RBBB morphology identifies patients with more severe bi-ventricular dysfunction on cardiac MRI and a poorer prognosis.

Introduction: Left atrial (LA) dimensions and volumes are important markers of cardiac dysfunction and portend an adverse cardiovascular outcome for patients with heart failure (HF), but LA function is rarely measured. Methods: Out-patients referred with suspected heart failure between 2000 and 2010 who underwent cardiac magnetic resonance imaging (CMRI) were included in this analysis. HF was defined as the presence of relevant symptoms and signs and evidence of cardiac dysfunction: either a left ventricular ejection fraction (LVEF) <50% or a raised amino-terminal pro-brain natriuretic peptide (NT-proBNP) >400 pg/ml (or >125 pg/ml for patients taking loop diuretics). LAEF was defined as (LA maximum volume-LA minimum volume)/LA maximum volume and was measured in both 2 and 4 chamber views. Results: Of 982 patients enrolled, 191 had atrial fibrillation, whilst 127 were considered not to have heart failure. The median (IQR) LAEF was 42 (31-51)% in patients with HF (in sinus rhythm) and 55 (48-61)% in patients with no HF (p<0.001). Comparing patients with HF in the lowest (23; IQR: 17-28%) and highest quartile of LAEF (56; IQR: 53-61%), those in the lowest quartile had lower LV and right ventricular (RV) EF, and increased LV and RV mass, as well as higher plasma NTproBNP. Overall, Log [LAEF] and log [NTproBNP] were correlated (r=-0.410, p<0.001). Of patients who had LAEF measured (those in sinus rhythm), 202 died during a median follow up of 1390 days (IQR: 763-2342). In a multivariable Cox regression model, LAEF, but not LVEF, was independently associated with an adverse outcome (HR for 10% change: 0.81 (95% CI: 0.74-0.90), p=0.001). NTproBNP and LAEF competed in the model with each providing similar prognostic information. During a median follow up of 1282 days (IQR: 701-2197), 101 patients developed atrial fibrillation (AF). Age (HR for 10 year change: 1.62 (95% CI: 1.23 - 2.14) p<0.001) and LAEF (HR for 10% change: 0.81 (95% CI: 0.66-0.90), p=0.044) were the only variables that independently predicted incident AF. Conclusions: In patients referred with suspected heart failure, LAEF identifies those with a higher risk of AF and an adverse outcome.