TAPSE/sPAP Ratio in Systemic Sclerosis: Evidence From Pulmonary Hypertension and Implications for Early Risk Stratification—A Systematic Review

PURPOSE: Cardiopulmonary involvement is a major determinant of morbidity and mortality in systemic sclerosis, particularly when pulmonary hypertension and right ventricular dysfunction develop. Increasing evidence suggests that prognosis in PH is more closely related to the ability of the right ventricle to adapt to increased afterload rather than to pulmonary pressure alone. The ratio between tricuspid annular plane systolic excursion and systolic pulmonary artery pressure has emerged as a simple echocardiographic surrogate of the interaction between right ventricular contractility and pulmonary vascular load. However, the clinical relevance of this index in systemic sclerosis across different disease stages has not been synthesized. METHODS: A systematic review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. The PubMed/MEDLINE database was searched for studies published between January 2006 and January 2026 evaluating the ratio between TAPSE/sPAP in adults with systemic sclerosis with and without overt PH. Eligible studies assessed the association between this index and clinical outcomes, including mortality, cardiovascular events, development of pulmonary hypertension, or disease progression. Study selection and data extraction were performed independently by two reviewers. Methodological quality was evaluated using a validated tool for prognostic studies. Due to heterogeneity in study populations, endpoints, and reported effect measures, results were synthesized narratively. RESULTS: Five observational studies met the inclusion criteria, encompassing a broad spectrum of systemic sclerosis phenotypes, ranging from screening cohorts without pulmonary hypertension to patients with catheterization-confirmed pulmonary hypertension. Across studies, lower values of the TAPSE/sPAP were consistently associated with worse clinical outcomes. Impaired coupling between the right ventricle and pulmonary circulation was also observed in some patients without overt pulmonary hypertension, suggesting that reduced right ventricular adaptation may occur early in the disease course. However, the proposed threshold values varied substantially across studies, reflecting differences in patient populations, study design, and clinical endpoints. CONCLUSIONS: Current evidence suggests that the ratio between TAPSE/sPAP may represent a clinically accessible marker of right ventricular adaptation to pulmonary vascular load in systemic sclerosis. Nevertheless, the available literature remains limited and largely observational, and proposed threshold values differ across clinical contexts. This index should therefore be interpreted within specific clinical scenarios rather than as a universal prognostic cut-off. Further prospective and multicenter studies are required to clarify TAPSE/sPAP role in screening, risk stratification, and longitudinal assessment of pulmonary vascular disease in systemic sclerosis.