Prognostic value of echocardiography-estimated right atrial pressure beyond the MAGGIC risk score in heart failure patients

Abstract

Venous congestion plays a central role in the pathophysiology of heart failure (HF). Echocardiography-estimated right atrial pressure (eRAP) provides a readily available non-invasive estimate of right-sided filling pressure and systemic venous congestion. However, it remains unclear whether eRAP can serve as a predictor of all-cause mortality in HF, and whether it can provide prognostic information beyond the scope of existing clinical risk assessments. This study investigated the association between eRAP and all-cause mortality in patients hospitalized for HF and evaluated its incremental prognostic value beyond the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score. This retrospective cohort study included 546 patients hospitalized for HF between January 2021 and December 2024. Patients were categorized as having normal (0–5 mmHg), borderline (5–10 mmHg), or elevated eRAP (10–20 mmHg) according to inferior vena cava (IVC) diameter and inspiratory collapsibility. The primary endpoint was all-cause mortality, with cardiovascular death and HF rehospitalization as secondary endpoints. Cox regression was used to evaluate the association between eRAP and all-cause mortality after adjustment for the MAGGIC risk score. The incremental prognostic value of eRAP beyond MAGGIC was assessed using discrimination, calibration, and decision-curve measures. During the follow-up period of 1,187.7 person-years, 232 deaths occurred. After adjustment for the MAGGIC risk score, patients in borderline eRAP group and elevated eRAP group had a significantly higher risk of the primary endpoint than those in normal eRAP group (borderline vs. normal: HR 1.47, 95% CI 1.09–1.99, P  = 0.012; elevated vs. normal: HR 1.69, 95% CI 1.22–2.34, P  = 0.001). Adding eRAP to the MAGGIC risk score provided modest incremental prognostic value, with improved discrimination (C-index, 0.665 vs. 0.650) and net clinical benefit within selected threshold probability ranges. Elevated eRAP was also associated with cardiovascular death after the MAGGIC risk score adjustment (sHR 1.81, 95% CI 1.26–2.60; P  = 0.001), whereas no significant association was observed with HF rehospitalization. eRAP was independently associated with all-cause and cardiovascular mortality in hospitalized patients with HF and provided modest incremental prognostic information beyond the MAGGIC risk score.