Prognostic role of right ventricular-pulmonary arterial coupling in acute myocardial infarction

Background: Right ventricular–pulmonary arterial (RV–PA) coupling, i.e. the relationship between right ventricle (RV) contractility and afterload, has emerged as a key determinant of outcomes in several cardiovascular conditions. However, evidence in acute myocardial infarction (AMI) remains limited. Purpose: To evaluate the prognostic value of RV–PA uncoupling, assessed by the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio, in predicting in-hospital and long-term adverse outcomes in AMI patients. Methods: We analyzed 1,230 consecutive AMI patients enrolled in the prospective AMIPE registry. TAPSE/PASP was measured at admission, and the optimal cut-off for predicting in-hospital events was determined using Youden’s index from receiver operating characteristic analysis. In-hospital events were defined as the occurrence of any of the following: all-cause death, recurrent AMI, clinically significant tachyarrhythmias or bradyarrhythmias, or ischemic stroke. Logistic regression identified predictors of in-hospital events, and Cox regression assessed long-term outcomes, including all-cause mortality and major adverse cardiovascular events (MACE). Results: The optimal cut-off value of the TAPSE/PASP ratio was 0.57 mm/mmHg; 26.3% of the total population presented a ratio ≤0.57 mm/mmHg. These patients were older, more frequently female, and exhibited a higher burden of comorbidities. At admission, they had lower left ventricular ejection fraction and right ventricular fractional area change, along with more pronounced diastolic dysfunction. RV–PA uncoupling independently predicted in-hospital events (adjusted odds ratio 4.01, 95% confidence interval [CI] 1.49–11.27, p = 0.006), as well as all-cause mortality (adjusted hazard ratio [HR] 2.08, 95% CI 1.30–3.33, p = 0.002) and MACE (adjusted HR 1.89, 95% CI 1.35–2.64, p < 0.001) during follow-up. Conclusions: The TAPSE/PASP ratio is a simple, noninvasive, and independent predictor of both in-hospital and long-term outcomes in AMI patients. RV–PA uncoupling identifies high-risk individuals, providing incremental prognostic value beyond traditional left ventricular parameters.