Right Ventricular End‐Ejection Pressure Predicts Mortality in Patients With Pulmonary Hypertension Associated With Heart Failure With Preserved Ejection Fraction

ABSTRACT Background Pulmonary hypertension associated with heart failure with preserved ejection fraction (PH‐HFpEF) is a syndrome in which right ventricular (RV) dysfunction influences prognosis. Conventional hemodynamic indices incompletely capture pulsatile components of RV afterload, which may contribute to inconsistent prognostic associations. We evaluated whether RV pressure (RVP) waveform analysis identifies determinants of prognosis in PH‐HFpEF beyond traditional measures. Methods We conducted a retrospective study of PH‐HFpEF patients between 2019 and 2025. RVP waveforms were analyzed to derive the pressure across the cardiac cycle and indices of pulsatile afterload. Associations with all‐cause mortality were assessed using LASSO‐penalized logistic regression and Cox proportional hazards models. Discrimination was evaluated using cross‐validated area under the receiver operating characteristic curve (AUC), time‐dependent AUCs, and Kaplan–Meier analysis. Results 80 patients (mean age 67; 65% female) were included (80% with combined post‐ and pre‐capillary pulmonary hypertension). Over median follow‐up of 985 days, 14 patients (17.5%) died. RV end‐ejection pressure (RVEEP), a late‐systolic measure reflecting RV pressure at pulmonic valve closure, was the only variable consistently retained in cross‐validated penalized regression analysis and demonstrated good discrimination for mortality (mean cross‐validated AUC 0.77). In a non‐penalized model, higher RVEEP was strongly associated with mortality ( β = 1.39, p = 0.00027; AUC 0.81). In multivariable Cox analysis incorporating RVEEP, right atrial/pulmonary arterial wedge pressure ratio, and NT‐proBNP, higher RVEEP remained independently associated with mortality (hazard ratio 1.82, 95% CI 1.11–2.99; p = 0.018). Conclusions Late‐systolic RV pressure dynamics captured by RVEEP are strongly associated with mortality in PH‐HFpEF, outperforming traditional hemodynamic indices for risk discrimination.