TAPSE/PASP ratio predicts worsening heart failure in patients with acute heart failure

Right ventricular (RV)–pulmonary artery (PA) coupling plays a pivotal role in acute heart failure (AHF), as RV failure often results from the inability of the RV to adapt to an abrupt increase in PA pressure. The tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio is a simple, non-invasive index that correlates closely with invasively assessed RV–PA coupling. While the prognostic significance of TAPSE/PASP is well established in pulmonary hypertension and chronic heart failure, evidence regarding its role in AHF remain limited.

This study aimed to assess the prognostic value of the TAPSE/PASP ratio, a surrogate marker of RV–PA coupling, in patients hospitalized for AHF.

The Sodium Nitroprusside Treatment in Acute Heart Failure (SNIP-AHF) study was a multicentre, retrospective analysis that included 200 patients hospitalized for AHF and treated with sodium nitroprusside. TAPSE and PASP values at admission were available for 136 patients, who constituted our study cohort. The primary endpoint was worsening heart failure (WHF), defined as clinical deterioration requiring intensification of diuretic and/or vasoactive therapy within 48 hours of admission.

Thirty-five patients (25.7%) developed WHF within 48 hours. Compared with patients without WHF, those with WHF were younger (median 58 vs. 63 years, p = 0.026). The TAPSE/PASP ratio at admission was significantly lower in the WHF group (0.27 vs. 0.32 mm/mmHg, p = 0.009), consistent with lower TAPSE values (14 vs. 16 mm, p = 0.040) and slightly higher PASP (53 vs. 48 mmHg, p = 0.067). Conventional prognostic markers - namely systolic blood pressure (105 vs. 105 mmHg, p = 0.793), central venous pressure (18 vs. 15 mmHg, p = 0.064), lactates (1.6 vs. 1.3 mmol/mol, p = 0.228), NT-proBNP (5576 vs. 6508 pg/mL, p = 0.816), and left ventricular ejection fraction (20% vs. 20%, p = 0.190) - did not differ significantly between groups (Figure 1). In multivariable analysis including TAPSE/PASP, TAPSE, PASP, age, and pH (all associated with WHF in univariable models), TAPSE/PASP emerged as the strongest independent predictor of WHF (OR 0.48, p = 0.025). The optimal TAPSE/PASP cut-off of 0.327 mm/mmHg yielded an AUC 0.65, with 80% sensitivity and 48% specificity (Figure 2).

In patients hospitalized for AHF and treated with sodium nitroprusside, a lower TAPSE/PASP ratio at admission was independently and inversely associated with the development of WHF within 48 hours, highlighting the clinical relevance of RV–PA coupling assessment in this setting.

Comparison between WHF and no-WHF