Clinical utility of non-invasive right ventricular pressure–strain loops for functional assessment and risk stratification in pulmonary hypertension
Y Wang, X Y Wang, L P LiuAbstract
Background
Right ventricular (RV) dysfunction is a key determinant of outcomes in pulmonary hypertension (PH). Non-invasive RV pressure–strain loop (PSL)–derived myocardial work may provide earlier and more sensitive assessment than conventional echocardiographic indices.
Methods
We enrolled 51 PH patients (October 2024–August 2025) and 20 healthy controls (PASP ≤35 mmHg). PH severity was stratified by echocardiographic pulmonary artery systolic pressure (PASP): mild (35–<50 mmHg, n=27), moderate (50–<70 mmHg, n=11), and severe (≥70 mmHg, n=13). All participants underwent standard echocardiography including RV function parameters and RV strain. RV PSL was constructed by integrating RV strain with echocardiography-estimated pulmonary pressures to derive RV myocardial work indices: RV global work index (RVGWI), constructive work (RVGCW), wasted work (RVGWW), and work efficiency (RVGWE). PH patients were followed for 3 months to assess treatment-related changes and short-term adverse clinical events. Associations with haemodynamics (mPAP), biomarkers (NT-proBNP), and CMR-derived RVEF were analysed. Diagnostic performance was evaluated by ROC curves, and measurement reliability by intraclass correlation coefficients (ICC). Cox regression was used for event prediction.
Results
Compared with controls, PH patients had lower RVGWI, RVGCW and RVGWE and higher RVGWW (all P<0.05). These indices showed stepwise deterioration with increasing disease severity/WHO functional class. PSL-derived parameters correlated significantly with mPAP and NT-proBNP and showed good agreement with CMR-derived RVEF. For early identification of RV dysfunction, RVGCW (AUC 0.867) and RVGWW (AUC 0.875) outperformed conventional indices such as TAPSE and RVFAC. After 3 months of therapy, RVGWI and RVGCW increased and RVGWW decreased (all P<0.05), with changes appearing earlier than improvements in traditional RV functional parameters. In Cox models, RVGWI <350 mmHg% and RVGWW >120 mmHg% independently predicted short-term adverse clinical events.
Conclusions
Non-invasive RV PSL-derived myocardial work indices display clear severity-dependent gradients, correlate with clinical phenotype and established RV function measures, and may improve early detection, therapeutic monitoring and short-term risk stratification in PH. Larger multicentre studies with longer follow-up are warrantedRVMWRV routine parameters