An association between right ventricular dysfunction and sudden cardiac death

Published:October 18, 2019DOI:


      The effectiveness of severely reduced left ventricular ejection fraction (LVEF <35%) as a predictor of sudden cardiac death (SCD) has diminished, and improvements in risk stratification await discovery of novel markers. Right ventricular (RV) abnormalities can be observed in conditions such as chronic obstructive pulmonary disease and sleep apnea, which have been linked to SCD.


      The purpose of this study was to evaluate whether RV abnormalities were associated with SCD after accounting for LVEF and other patient characteristics.


      In a large, prospective ongoing community-based study of SCD in the Portland, Oregon, metropolitan area, SCD cases (age ≥18 years; 2002–2014) were compared to controls with coronary artery disease but no SCD. Using a novel archive of digital echocardiograms, a standardized approach was used to evaluate RV basal diameter, RV end-diastolic area, and right ventricular fractional area change (RVFAC).


      A total of 350 subjects were studied, including 81 SCD cases (age 68.7 ± 13.6 years; 73% male) and 269 controls (age 66.5 ± 10.2 years; 69% male). In multivariate analysis, RVFAC was significantly associated with SCD (odds ratio 1.14 for each 5% decrease; 95% confidence interval 1.03–1.25; P = .01). When modeled with LVEF ≤35%, RVFAC ≤35% was significantly associated with increased risk of SCD. Individuals with both left ventricular and RV dysfunction had a 3× higher odds of SCD than those with neither (odds ratio 3.19; 95% confidence interval 1.33–7.68; P = .01).


      RV dysfunction was associated with a significantly increased risk of SCD independent of LVEF and, when combined with LVEF, had additive effects on SCD risk.


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        • Benjamin E.J.
        • Virani S.S.
        • Callaway C.W.
        • et al.
        Heart disease and stroke statistics—2018 update: a report from the American Heart Association.
        Circulation. 2018; 137: e67-e492
        • Bardy G.H.
        • Lee K.L.
        • Mark D.B.
        • et al.
        Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure.
        N Engl J Med. 2005; 352: 225-237
        • Moss A.J.
        • Zareba W.
        • Hall W.J.
        • et al.
        Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.
        N Engl J Med. 2002; 346: 877-883
        • Epstein A.E.
        • Dimarco J.P.
        • Ellenbogen K.A.
        • et al.
        ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities.
        Heart Rhythm. 2008; 5: e1-e62
        • Chugh S.S.
        • Reinier K.
        • Teodorescu C.
        • et al.
        Epidemiology of sudden cardiac death: clinical and research implications.
        Prog Cardiovasc Dis. 2008; 51: 213-228
        • Chugh S.S.
        • Uy-Evanado A.
        • Teodorescu C.
        • et al.
        Women have a lower prevalence of structural heart disease as a precursor to sudden cardiac arrest: the Ore-SUDS (Oregon Sudden Unexpected Death Study).
        J Am Coll Cardiol. 2009; 54: 2006-2011
        • Sabbag A.
        • Suleiman M.
        • Laish-Farkash A.
        • et al.
        Contemporary rates of appropriate shock therapy in patients who receive implantable device therapy in a real-world setting: from the Israeli ICD Registry.
        Heart Rhythm. 2015; 12: 2426-2433
        • Stecker E.C.
        • Chugh S.S.
        Prediction of sudden cardiac death: next steps in pursuit of effective methodology.
        J Interv Card Electrophysiol. 2011; 31: 101-107
        • Stecker E.C.
        • Vickers C.
        • Waltz J.
        • et al.
        Population-based analysis of sudden cardiac death with and without left ventricular systolic dysfunction: two-year findings from the Oregon Sudden Unexpected Death Study.
        J Am Coll Cardiol. 2006; 47: 1161-1166
        • Konety S.H.
        • Koene R.J.
        • Norby F.L.
        • et al.
        Echocardiographic predictors of sudden cardiac death: the Atherosclerosis Risk in Communities Study and Cardiovascular Health Study.
        Circ Cardiovasc Imaging. 2016; 9: e004431
        • Narayanan K.
        • Reinier K.
        • Uy-Evanado A.
        • et al.
        Chronic obstructive pulmonary disease and risk of sudden cardiac death.
        JACC Clin Electrophysiol. 2015; 1: 381-387
        • Gami A.S.
        • Olson E.J.
        • Shen W.K.
        • et al.
        Obstructive sleep apnea and the risk of sudden cardiac death: a longitudinal study of 10,701 adults.
        J Am Coll Cardiol. 2013; 62: 610-616
        • Rubin L.J.
        • American College of Chest Physicians
        Diagnosis and management of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.
        Chest. 2004; 126: 7S-10S
        • Zangiabadi A.
        • De Pasquale C.G.
        • Sajkov D.
        Pulmonary hypertension and right heart dysfunction in chronic lung disease.
        Biomed Res Int. 2014; 2014: 739674
        • Cuttica M.J.
        • Kalhan R.
        • Shlobin O.A.
        • et al.
        Categorization and impact of pulmonary hypertension in patients with advanced COPD.
        Respir Med. 2010; 104: 1877-1882
        • Minai O.A.
        • Ricaurte B.
        • Kaw R.
        • et al.
        Frequency and impact of pulmonary hypertension in patients with obstructive sleep apnea syndrome.
        Am J Cardiol. 2009; 104: 1300-1306
        • Chugh S.S.
        • Jui J.
        • Gunson K.
        • et al.
        Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. community.
        J Am Coll Cardiol. 2004; 44: 1268-1275
        • Devereux R.B.
        • Lutas E.M.
        • Casale P.N.
        • et al.
        Standardization of M-mode echocardiographic left ventricular anatomic measurements.
        J Am Coll Cardiol. 1984; 4: 1222-1230
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Dutta T.
        • Aronow W.S.
        Echocardiographic evaluation of the right ventricle: clinical implications.
        Clin Cardiol. 2017; 40: 542-548
        • Aktas M.K.
        • Kim D.D.
        • McNitt S.
        • et al.
        Right ventricular dysfunction and the incidence of implantable cardioverter-defibrillator therapies.
        Pacing Clin Electrophysiol. 2009; 32: 1501-1508
        • Mikami Y.
        • Jolly U.
        • Heydari B.
        • et al.
        Right ventricular ejection fraction is incremental to left ventricular ejection fraction for the prediction of future arrhythmic events in patients with systolic dysfunction.
        Circ Arrhythm Electrophysiol. 2017; 10: e004067
        • Risum N.
        • Valeur N.
        • Søgaard P.
        • Hassager C.
        • Køber L.
        • Ersbøll M.
        Right ventricular function assessed by 2D strain analysis predicts ventricular arrhythmias and sudden cardiac death in patients after acute myocardial infarction.
        Eur Heart J Cardiovasc Imaging. 2018; 19: 800-807
        • Naksuk N.
        • Tan N.
        • Padmanabhan D.
        • et al.
        Right ventricular dysfunction and long-term risk of sudden cardiac death in patients with and without severe left ventricular dysfunction.
        Circ Arrhythm Electrophysiol. 2018; 11: e006091
        • Lee J.Z.
        • Low S.W.
        • Pasha A.K.
        • Howe C.L.
        • Lee K.S.
        • Suryanarayana P.G.
        Comparison of tricuspid annular plane systolic excursion with fractional area change for the evaluation of right ventricular systolic function: a meta-analysis.
        Open Heart. 2018; 5: e000667
        • Nakamori S.
        • Onishi K.
        • Ishida M.
        • et al.
        Myocardial perfusion reserve is impaired in patients with chronic obstructive pulmonary disease: a comparison to current smokers.
        Eur Heart J Cardiovasc Imaging. 2014; 15: 180-188
        • Sievi N.A.
        • Clarenbach C.F.
        • Camen G.
        • Rossi V.A.
        • van Gestel A.J.
        • Kohler M.
        High prevalence of altered cardiac repolarization in patients with COPD.
        BMC Pulm Med. 2014; 14: 55
        • Zulli R.
        • Donati P.
        • Nicosia F.
        • et al.
        Increased QT dispersion: a negative prognostic finding in chronic obstructive pulmonary disease.
        Intern Emerg Med. 2006; 1: 279-286
        • Nakamura T.
        • Chin K.
        • Hosokawa R.
        • et al.
        Corrected QT dispersion and cardiac sympathetic function in patients with obstructive sleep apnea-hypopnea syndrome.
        Chest. 2004; 125: 2107-2114
        • Somers V.K.
        • Dyken M.E.
        • Clary M.P.
        • Abboud F.M.
        Sympathetic neural mechanisms in obstructive sleep apnea.
        J Clin Invest. 1995; 96: 1897-1904
        • Chugh S.S.
        • Uy-Evanado A.
        Improved prediction of sudden cardiac death risk: staying within the echocardiogram but extending beyond the ejection fraction.
        Circ Cardiovasc Imaging. 2016; 9: e005133
        • Reinier K.
        • Dervan C.
        • Singh T.
        • et al.
        Increased left ventricular mass and decreased left ventricular systolic function have independent pathways to ventricular arrhythmogenesis in coronary artery disease.
        Heart Rhythm. 2011; 8: 1177-1182