Aims: Chronic kidney disease (CKD) and right ventricular (RV) dysfunction are important predictors of prognosis in heart failure (HF). We investigated the relationship between RV dysfunction and CKD in outpatients with chronic systolic HF, an association which remains poorly defined. Methods and results: Outpatients (n = 373) with chronic HF and left ventricular ejection fraction (LVEF) ≤45% underwent clinical and echo-Doppler evaluations and were followed up for 31 ± 24 months. Tricuspid annular plane systolic excursion (TAPSE) assessed RV dysfunction. The estimated glomerular filtration rate (GFR) was measured by the simplified Modification of Diet in Renal Disease (MDRD) formula. Correlation analysis was used to characterize the association between TAPSE and estimated GFR. Odds ratios (ORs) for CKD and hazard ratios (HRs) for all-cause mortality were assessed using multivariable logistic or proportional hazards regression models. TAPSE and estimated GFR were significantly correlated (r = 0.38, P < 0.0001). TAPSE ≤14 mm was associated with elevated estimated right atrial pressure and N-terminal pro brain natriuretic peptide levels. TAPSE ≤14 mm increased the odds of estimated GFR <60 mL/min/1.73 m2, OR [95% confidence interval (CI)] = 2.51(1.44–4.39), P < 0.0001 and predicted all-cause mortality, HR (95% CI) = 1.80 (1.20–2.71) after multivariable adjustment. Conclusions: Right ventricular dysfunction is cross-sectionally associated with CKD and prospectively predicts survival in outpatients with chronic systolic HF. These data suggest RV dysfunction to be one of the possible mechanistic links between HF and CKD.

Aims To test a decision model for non-invasive estimation of left ventricular filling pressure (LVFP) in patients with left ventricular (LV) dysfunction and a wide range of ejection fractions (EF). Methods and results In patients with LV dysfunction ( n = 270; EF = 42 ± 16%), classification and regression tree (CART) analysis was used to generate a model for the prediction of elevated LVFP, defined as pulmonary capillary wedge pressure (PCWP) >15 mmHg, in a derivation cohort ( n = 178). At each step of the decision tree, nodes including single or multiple criteria connected by Boolean operators were tested to achieve the best information entropy gain. Averaged mitral-to-myocardial early velocities ratio ( E / e ′) ≥13 OR E-wave deceleration time 15 mmHg needed the following criteria to be satisfied: (i) intermediate E / e ′ (13 > E / e ′ > 8); (ii) left atrial volume index >40 mL/m2 OR ratio of mitral E-wave and colour M-mode propagation velocity >2 OR difference in duration of pulmonary vein and mitral flow at atrial contraction >30 ms; (iii) estimated pulmonary artery systolic pressure >35 mmHg. Patients were correctly allocated according to PCWP with an 87% sensitivity and a 90% specificity. Compared with the best single parameter estimating LVFP, a 17% relative increase in accuracy was achieved in patients with EF >50%. The model was prospectively validated in a testing group ( n = 92): 80% sensitivity, 78% specificity. Conclusion This sequential testing is useful to non-invasively predict LVFP in patients with LV dysfunction, especially in those with preserved EF.

Objective To ascertain whether increasing doses of orally administered furosemide are associated with impaired survival in outpatients with chronic heart failure (CHF) and left ventricular (LV) systolic dysfunction. Methods Transthoracic echo‐Doppler examination was carried out at baseline in 813 consecutive CHF outpatients with LV ejection fraction ≤ 45%. The total daily dose of furosemide was assessed for each patient. Chronic kidney disease (CKD) was defined by a glomerular filtration rate < 60 ml/min/1.73 m². The end‐point was all‐cause mortality. To control the prognostic effect of furosemide for the propensity of using high doses of the drug, the Cox model was stratified by the propensity score, itself computed from a multivariable logistic model. Mean follow up was 44 months. Results After stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide dose (HR 1.38, 95% CI 1.14–1.68, p < 0.001). A daily dose of 50 mg was identified as the best threshold value to predict a high risk of death within 3 years with an area under the ROC curve of 0.68 (95% CI 0.64–0.72). Increasing doses of furosemide were associated with an increased risk of death regardless of LV filling pattern, CKD and background therapy with ACE‐inhibitors or beta‐blockers. Conclusions In outpatients with CHF, after stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide daily dose. A threshold furosemide dose of 50 mg was related with the worse outcome.