Right ventricular-pulmonary arterial uncoupling: an underrecognized predictor of in-hospital outcomes in acute myocardial infarction

BACKGROUND: Right ventricular (RV) function is an underrecognized determinant of outcomes in acute myocardial infarction (AMI) and is not routinely incorporated into risk stratification. Beyond primary RV involvement, interventricular interdependence and ventriculoarterial coupling suggest a more substantial role of the RV in acute hemodynamic adaptation than previously appreciated. The TAPSE/sPAP ratio, a non-invasive index of RV-pulmonary arterial (RV-PA) coupling reflecting the interaction between RV function and afterload, may capture this interaction, but its prognostic role in AMI remains insufficiently defined. METHODS: We retrospectively analyzed 290 consecutive AMI patients (138 STEMI, 152 NSTEMI). The primary endpoint was in-hospital major adverse events (MAE), defined as a composite of all-cause mortality, recurrent myocardial infarction, acute decompensated heart failure, acute kidney injury, stroke, or major bleeding. Multivariable logistic regression was performed to evaluate the prognostic value of TAPSE/sPAP. A sensitivity analysis was conducted using major adverse cardiovascular events (MACE), defined as the composite of in-hospital events excluding major bleeding. RESULTS: MAE occurred in 53 patients (18.3%). In multivariable analysis, TAPSE/sPAP was an independent predictor of MAE (OR 0.16, 95% CI 0.03-0.73, p = 0.017). Chronic kidney disease and Shock Index also remained significant predictors, whereas LVEF was not independently associated. Sensitivity analysis using MACE confirmed the prognostic value of TAPSE/sPAP (OR 0.12, 95% CI 0.02-0.62, p = 0.011). ROC analysis identified a TAPSE/sPAP threshold of 0.47 mm/mmHg, with 83.3% sensitivity and 85.6% specificity for predicting MAE. CONCLUSIONS: The TAPSE/sPAP ratio is a non-invasive independent predictor of in-hospital complications in AMI and remains associated with adverse outcomes after adjustment for clinical risk factors. Early assessment of RV-pulmonary arterial coupling may improve identification of high-risk patients and guide targeted clinical management.