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The VIRTUE Index: A Novel Echocardiographic Marker Integrating Right-Left Ventricular Hemodynamics in Acute Heart
Dan-Cristian Popescu1,2,3, Mara Ciobanu1,2,3, Diana Țînț3,4
1Department of Cardiology, Clinical Emergency Hospital "Sfântul Pantelimon", 021652 Bucharest, Romania.
Insights
The Virtue Index, a novel hemodynamic measure, shows promise for predicting short-term mortality in acute heart failure (AHF), particularly in HFpEF patients. While NT-proBNP remains superior, this index offers a valuable bedside tool for risk assessment.
Area of Science:
- Cardiology
- Clinical Echocardiography
- Heart Failure Pathophysiology
Background:
- Acute heart failure (AHF) is a complex syndrome with prognosis varying by phenotype.
- Standard echocardiographic measures provide limited prognostic information in AHF.
- The Virtue Index integrates right and left ventricular function to assess hemodynamic interactions.
Purpose of the Study:
- To evaluate the clinical and prognostic performance of the Virtue Index in AHF patients.
- To assess the Virtue Index's behavior across different ejection fraction phenotypes (HFpEF and HFrEF).
- To compare the Virtue Index's predictive accuracy against NT-proBNP and other echocardiographic parameters.
Main Methods:
- Retrospective analysis of 222 AHF patients, with 168 having complete data for Virtue Index calculation.
- Spearman correlation assessed the relationship between the Virtue Index and NT-proBNP.
- Receiver Operating Characteristic (ROC) analysis evaluated in-hospital mortality prediction.
Main Results:
- In HFpEF, the Virtue Index showed moderate correlation with NT-proBNP and fair prognostic discrimination (AUC 0.704).
- In HFrEF, the Virtue Index had weak correlation with NT-proBNP and modest predictive accuracy (AUC 0.584).
- NT-proBNP consistently outperformed all echocardiographic parameters in both HFpEF and HFrEF groups.
Conclusions:
- The Virtue Index demonstrates phenotype-dependent prognostic value in AHF, being more informative in HFpEF.
- The Virtue Index may complement NT-proBNP for rapid, bedside estimation of short-term mortality risk in AHF.
- Further validation is needed, but the Virtue Index offers a novel approach to integrated hemodynamic assessment in AHF.
Abstract:
Background/Objectives: Acute heart failure (AHF) is a heterogeneous syndrome with phenotype-dependent prognosis. NT-proBNP is the reference biomarker, but standard echocardiographic measures (TAPSE, RV-RA gradient, LVOT VTI) offer only partial prognostic insight. The Virtue Index, defined as (RV-RA gradient)/(TAPSE × LVOT VTI), was introduced to integrate right-left ventricular interaction. This study evaluated its clinical and prognostic performance in AHF and its behavior across ejection-fraction phenotypes. Methods: We retrospectively analyzed 222 patients with AHF; complete data for Virtue calculation were available in 168 (99 HFrEF, 69 HFpEF) patients. HFmrEF patients were excluded from subgroup prognostic analyses. Correlation with NT-proBNP was assessed using Spearman testing with bootstrap intervals, and in-hospital mortality prediction was evaluated using ROC analysis with DeLong comparisons. Results: In HFpEF, the Virtue Index correlated moderately with NT-proBNP (ρ = 0.38, p = 0.002) and showed fair prognostic discrimination (AUC 0.704), similar to the RV-RA gradient (0.724) and higher than TAPSE or LVOT VTI. In HFrEF, correlation was weak (ρ = 0.19, p = 0.06) and predictive accuracy was modest (AUC 0.584), while LVOT VTI performed best (AUC 0.700). NT-proBNP outperformed all echocardiographic parameters in both groups. Conclusions: The Virtue Index reflects integrated hemodynamics and shows phenotype-dependent prognostic value in AHF, being more informative in HFpEF than in HFrEF. Although NT-proBNP remained superior, Virtue may complement biomarker-based risk assessment by offering a rapid, bedside estimate of short-term mortality risk.
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