Ventriculo-arterial coupling in acute heart failure: prognostic and therapeutic insights - a systematic review and meta-analysis of multivariable-adjusted data.

In acute heart failure (AHF), non-invasive ventricular-arterial coupling (VAC) surrogates, including right ventricular-pulmonary arterial (RV-PA) and left ventricular-arterial (LV-Ao) coupling, have emerged as practical bedside indices, but their prognostic significance remains largely unknown systematically. We performed a systematic review and meta-analysis to evaluate the prognostic significance of non-invasive VAC assessment, in patients hospitalized with AHF. Outcomes included all-cause mortality, HF hospitalization, length of hospital stay, use of therapies, the composite of all-cause mortality and HF hospitalization, and in-hospital adverse cardiovascular events. Adjusted hazard ratios (aHRs) and odds ratios (aORs) were pooled using random-effects. Subgroup-analyses were performed according to follow-up duration and left ventricular ejection fraction. Thirty-six studies comprising 36,989 patients were analysed. Twenty-eight studies evaluated RV-PA coupling, predominantly the TAPSE/PASP ratio, and eight evaluated LV-Ao coupling, mainly using non-invasive Ea/Ees estimates. RV-PA uncoupling was independently associated with increased all-cause mortality (aHR 1.90; 95% CI 1.42-2.56; I²=49%), with consistent associations at 12 months (aHR 2.03; 95% CI 1.44-2.85) and long-term follow-up (aHR 1.67; 95% CI 1.06-2.64). Associations with HF hospitalization, hospital stay, and the composite endpoint were directionally consistent but not statistically significant. LV-Ao uncoupling was associated with increased in-hospital adverse cardiovascular events (aOR 1.70; 95% CI 1.29-2.24). Sensitivity analyses confirmed robustness of these findings. RV-PA uncoupling predicts mortality, whereas LV-Ao uncoupling identifies patients at increased risk of in-hospital adverse cardiovascular events, supporting VAC-risk-stratification in AHF and future evaluation of VAC-guided therapeutic strategies.