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Aims: Right ventricle adaptation to prolonged exposure against pulmonary hypertension (PH) includes structural and functional abnormalities, translated into modifications of blood flow pattern through the right coronary artery. Given these changes, we investigate the relationship between right coronary artery diastolic perfusion pressure (RCDPP) and clinical outcome, in patients with PH secondary to left-sided heart failure (HF)., Methods and Results: We studied 108 HF patients who underwent right heart catheterization. PH was present in 75 (69.4%). Mean RCDPP was lower in patients with PH (59.4 ± 14.0 mmHg) as compared with no PH patients (65.5 ± 11.6 mmHg) (P = 0.03). Aortic diastolic pressure accounted for 79% of RCDPP variability explained by the model (P < 0.0001). During a median follow-up of 26 months, the RCDPP 1st tertile (<55 mmHg) [hazard ration (HR) 5.19, 95% confidence interval (CI) 1.08-25.12, P = 0.04] and left ventricular ejection fraction <45% [HR 7.26, 95% CI 1.77-29.73, P = 0.006] were independent predictors of mortality., Conclusions: Right coronary artery diastolic perfusion pressure is a strong independent haemodynamic maker of mortality in left-sided HF and PH. Excessive reduction of aortic diastolic pressure may be detrimental. Future research is necessary to determine the therapeutic approach to blood pressure in this population., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)