Prognostic value of left ventricular ejection fraction versus right ventricular ejection fraction in patients with cardiovascular diseases: a systematic review and meta-analysis

Abstract Background Although it is known that cardiovascular magnetic resonance (CMR)-derived right ventricular ejection fraction (RVEF) is significantly associated with adverse events in patients with cardiovascular diseases (CVDs), little is known about whether its association is stronger than that of left ventricular ejection fraction (LVEF). Purpose We aimed to investigate and compare the prognostic value of LVEF and RVEF in predicting adverse outcomes in patients with CVDs using systematic review and meta-analysis. Methods We searched three electronic databases for articles reporting hazard ratios (HRs) for both CMR-derived LVEF and RVEF in patients with CVDs on September 26, 2025. We rescaled the HRs by standard deviation (SD) within each study, and then calculated the HRs per 1-SD decrease in LVEF and RVEF. We also calculated the ratio of HRs to directly compare LVEF and RVEF. Results A total of 114 articles, including 25,839 patients, were eligible for inclusion in this study and were categorized into 14 CVDs. Although the HR per 1-SD reduction in LVEF showed no statistically significant association with adverse events in the heart failure with preserved ejection fraction (HFpEF) (HR: 1.00, 95% confidence interval [CI]: 0.87-1.14), non-ischemic cardiomyopathy (NICM) (HR: 1.47, 95% CI: 0.91-2.36), arrhythmogenic right ventricular cardiomyopathy (ARVC) (HR: 1.40, 95% CI: 0.93-2.09), myocarditis (HR: 1.41, 95% CI: 0.76-2.60) and valvular heart disease (VHD) (HR: 1.16, 95% CI: 0.88-1.53), the other nine CVDs showed significant associations with adverse outcomes. Conversely, the HR per 1-SD reduction in RVEF was statistically significant for all CVDs (HR: 1.29-1.79) except for myocarditis (HR: 1.29, 95% CI: 0.62-2.67). Additionally, the ratio of HR for RVEF to LVEF was significantly greater than 1 in congenital heart disease (CHD) (HR: 1.24, 95% CI: 1.00-1.54), HFpEF (HR: 1.27, 95% CI: 1.10-1.47), ARVC (HR: 1.24, 95% CI: 1.02-1.49) and pulmonary hypertension (PH) (HR: 1.22, 95% CI: 1.11-1.33). Conclusion Reduced RVEF was associated with adverse outcomes in all specific types of CVDs except myocarditis. However, reduced LVEF was not shown to significantly impact prognosis in HFpEF, NICM, ARVC, myocarditis and VHD. In CHD, HFpEF, ARVC and PH, lower RVEF was more strongly associated with adverse clinical outcomes than lower LVEF.Table 1:HR for each CVDs Figure 1:Forest plot of ratio of HR