Updated Multimodality Evidence on Right Ventricular Dysfunction and Pulmonary Hypertension in HFpEF: A Systematic Review and Meta-analysis

Aim This study aimed to determine the pooled prevalence of right ventricular dysfunction (RVD) and pulmonary hypertension (PH) in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we analyzed 73 studies (20,175 patients with HFpEF) using random-effects meta-analysis. Echocardiographic RVD prevalence demonstrated remarkable consistency across functional and structural parameters: 25.9% by tricuspid annular plane systolic excursion (TAPSE), 23.9% by fractional area change (FAC), 22.3% by tricuspid annular systolic velocity (RV S’), 28.3% by right ventricular global longitudinal strain (GLS), and 22.9% by RV dilation criteria. Notably, the cardiovascular magnetic resonance-derived RV ejection fraction (CMR-RVEF < 45%) showed 16.1% prevalence versus 39.5% using the tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) ratio. Composite diagnostic criteria (≥ 2 abnormal parameters) exhibited higher detection sensitivity than single-parameter thresholds (38.3% vs. 24.5%). PH prevalence diverged substantially between invasive (mean pulmonary arterial pressure [MPAP], 64.1%) and echocardiographic (PASP, 46.7%) assessments. Metabolic syndrome components amplified RVD risk in a dose-dependent manner (diabetes > 40%: 28.4% vs. 18.8%, hypertension > 75%: 29.6% vs. 13.9%, and obesity > 30%: 30.9% vs. 10.6%). Conclusion Patients with HFpEF exhibit a substantial RVD/PH burden, necessitating a systematic right heart evaluation. Composite multimodality criteria optimize the early detection sensitivity, whereas metabolic dysregulation may emerge as a potent risk amplifier.