Background Risk stratification is a crucial issue in heart failure. Clinicians seek useful tools to tailor therapies according to patient risk. Methods A prospective, observational, multicenter study on stable chronic heart failure outpatients with reduced left ventricular ejection fraction (HFrEF). Baseline demographics, blood, natriuretic peptides (NPs), high-sensitivity troponin I (hsTnI), and echocardiographic data, including the ratio between tricuspid annular plane excursion and systolic pulmonary artery pressure (TAPSE/PASP), were collected. Association with death for any cause was analyzed. Results Four hundred thirty-one (431) consecutive patients were enrolled in the study. Fifty deaths occurred over a median follow-up of 32 months. On the multivariable Cox model analysis, TAPSE/PASP ratio, number of biomarkers above the threshold values, and gender were independent predictors of death. Both the TAPSE/PASP ratio ≥0.36 and TAPSE/PASP unavailable groups had a three-fold decrease in risk of death in comparison to the TAPSE/PASP ratio <0.36 group. The risk of death increased linearly by 1.6 for each additional positive biomarker and by almost two for women compared with men. Conclusions In a HFrEF outpatient cohort, the evaluation of plasma levels of both NPs and hsTnI can contribute significantly to identifying patients who have a worse prognosis, in addition to the echocardiographic assessment of right ventricular-arterial coupling.

Purpose.We previously re-validated noninvasive estimation of pulmonary wedge pressure (PWP) measuring the CW pulmonary valve regurgitation end-diastolic pressure gradient (PWPecho).Using the latter as surrogate of PWP, we sought to test accuracy of left ventricular (LV) filling pressures estimation by the EAE guidelines algorithm (EAEalg) in a large non-selected population.Methods.We studied 1019 patients in sinus rhythm with GE Vivid7/9 systems (age: 10-93 y.; EF%: 13-83%, normal, n= 827 and reduced ,50%, n= 192), in whom PWPecho could be measured (feasibility 75%), with normal pulmonary vascular resistances (WU, 2).The EAEalg combined E/e' (average), left atrial volume (LAV), E/A, Edec, pulmonary venous systolic fraction (SF), and echo-derived pulmonary systolic pressure (PSPe) to obtain 3 groups: normal, high PWP and not classifiable.These were compared to the PWPecho estimate.Results: Feasibility was high for all variables (E/E' 90%, LAV 93%, E/A 95%, Edec 90%, SF 91%, PSPe 92%), and for the EAEAlg (94%).Using the EAEAlg, 17% (n=137) of patients with normal in contrast to 10% (n=19) of patients with EF,50% were not classifiable, in the former secondary to the combination of a E/E'= 9-13 range, and LAV≥ 34ml/m2.In the remaining (classified, 84%) patients, utility of EAEalg even when limited to patients with EF,50% was still hampered by a low positive predictive value (PPV) (Table ).Further, when only E/e' was tested in the same patients at ROC analysis (cutoff= 15; AUC=0.72,CI:0.6-0.8),accuracy was still impaired by a low PPV (53%), albeit a fair negative predictive value (NPV) (79%).Correlation between PWPecho and E/e' was modest even in patients with EF,50% (r=0.4,p,0.001), and at multiple regression analysis, E/ e' was independently determined by age and mitral regurgitation in all patients, and by LV end-diastolic volume in EF,50% (r= 0.7, p,0.001) and by LV mass index in EF.50% (r= 0.64, p,.001).Conclusions.Noninvasive estimation of PWP by EAE guidelines is limited by a low PPV in both patients with and without reduced LV EF.In this setting, utility of the E/e' is limited, it being influenced by patient age, preload and LV mass.