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Preliminary data suggest that right heart failure (RHF) may be more common in urban Africans than first suspected. We examined the characteristics and pathways to RHF in the Heart of Soweto cohort.A clinical registry captured data from 5328 de novo presentations of heart disease to the Cardiology Unit, Chris Hani Baragwanath Hospital in Soweto, South Africa during 2006–08. Of 2505 cases of HF (47% of total cohort), 697 (28%) were diagnosed with RHF (50% primary diagnosis). Despite more females than males (379 vs. 318 cases), proportionately more men presented with RHF [15 vs. 12% of cases; odds ratios (OR) 1.27, 95% confidence intervals (CI) 1.08–1.49] and Africans predominated overall (n= 642, 92%). Apart from concurrent left-sided heart disease (213 cases, 31%) there were many pathways to RHF including chronic lung disease (179 cases, 26% including COPD and tuberculosis) and 141 cases (20%) of pulmonary arterial hypertension (PAH). On an adjusted basis, women were almost two-fold more likely to present with PAH (OR 1.72, 95% CI 1.17–2.55; P= 0.006) while those with low levels of education (OR 0.69, 95% CI 0.47–1.01; P= 0.054) and originating from Soweto (OR 0.64, 95% CI 0.42–0.96; P= 0.029) were less likely to present with PAH compared with the rest of the cohort.These data suggest cases of RHF and related PAH are relatively common among urban Africans presenting with de novo heart disease.