Echocardiographic estimation of pulmonary arterial systolic pressure in acute heart failure. Prognostic implications

Prognostic Markers of Adverse Outcomes in Acute Heart Failure: Use of Machine Learning and Network Analysis with Real Clinical Data

Background: Acute heart failure (AHF) is one of the leading causes of admissions to the emergency department (ED). There is a need to develop an easy-to-use score that can be used in the ED to risk-stratify patients with AHF and in hospitalization decisions regarding cardiac wards or intensive care units (ICUs). Methods: A retrospective observational study was conducted at a city hospital. The data from the presentation of AHF patients at the ED were collected. The combined primary endpoint included death from any cause during hospitalization or transfer to an intensive care unit (ICU) for using inotropes/vasopressors. Feature selection was performed using artificial intelligence. Results: From August 2020 to August 2021, 908 patients were enrolled (mean age: 71.6 ± 13 years; 500 (55.1%) men). We found significant predictors of in-hospital mortality and ICU transfers for inotrope/vasopressor use and built two models to assess the need for ICU admission of patients from the ED. The first model included SpO2 < 90%, QTc duration, prior diabetes mellitus and HF diagnosis, serum chloride concentration, respiratory rate and atrial fibrillation on admission, blood urea nitrogen (BUN) levels, and any implanted devices. The second model included left ventricular end-diastolic size, systolic blood pressure, pulse blood pressure, BUN levels, right atrium size, serum chloride, sodium and uric acid concentrations, prior loop diuretic use, and pulmonary artery systolic blood pressure. Conclusions: We developed two models that demonstrated a high negative predictive value, which allowed us to distinguish patients with low risk and determine patients who can be hospitalized and sent from the ED to the floor. These easy-to-use models can be used at the ED.

Under pressure: symptomatic pulmonary hypertension is a predictor of poor outcome following hip fracture

INTRODUCTION

Pulmonary hypertension (PHTN) is associated with increased morbidity and mortality in noncardiac surgery and elective surgery. This population of patients has a low physiological reserve and is prone to cardiac arrest as a result. This study aims to identify the impact that PHTN has on outcomes among geriatric hip fracture patients.

METHODS

A 3:1 propensity-score-matched retrospective case (PHTN)-control (no PHTN [N]) study of hip fracture patients from 2014 to 2022 was performed. Patients were matched utilizing propensity score matching of a validated geriatric trauma risk assessment tool (STTGMA). All patients were reviewed for hospital quality measures and outcomes. Comparative univariable and multivariable analyses were conducted between the two matched cohorts. A sub-analysis compared patients across PHTN severity levels (mild, moderate, severe) based on pulmonary artery systolic pressures (PASP) as measured by transthoracic echocardiogram.

RESULTS

PHTN patients (n = 67) experienced a higher rate of inpatient, 30-day, and 1-year mortality, major complications, and 90-day readmissions as compared to the N cohort (n = 201). PHTN patients with a PASP > 60 experienced a significantly higher rate of major complications, need for ICU, longer admission length, and worse 1-year functional outcomes. Pulmonary hypertension was found to be independently associated with a 3.5 × higher rate of 30-day mortality (p = 0.016), 2.7 × higher rate of 1-year mortality (p = 0.008), 2.5 × higher rate of a major inpatient complication (p = 0.028), and 1.2 × higher rate of 90-day readmission (p = 0.044).

CONCLUSION

Patients who had a prior diagnosis of pulmonary hypertension before sustaining their hip fracture experienced significantly worse inpatient and post-discharge outcomes. Those with a PASP > 60 mmHg had worse outcomes within the PHTN cohort. Providers must recognize these at-risk patients at the time of arrival to adjust care planning accordingly.

LEVEL OF EVIDENCE

III.

Use of remote patient monitoring kits to reduce hospitalization and mortality rates for patients with heart failure

PURPOSE

Patients with heart failure (HF) are at an increased risk of volume overload, which can lead to hospital admission. Use of noninvasive remote patient monitoring (RPM) devices utilizing biometric sensors and weighing scales to track vital signs and body weight has uncertain benefits. At the Baptist Health Louisville (BHLOU) HF Clinic, high-risk patients were given RPM kits. The purpose of this study was to determine whether RPM led to reductions in HF hospitalizations and mortality.

METHODS

This single-center, retrospective chart review evaluated adult patients presenting to the BHLOU HF Clinic after a recent hospitalization for HF or need for intravenous diuretics within the past 60 days. The study evaluated patients before and after implementation of RPM kits. The primary endpoints were differences in the rates of 30-day HF hospitalization and 30-day mortality. Secondary endpoints included differences in the number of interventions in 90 days, the 90-day rate of HF hospitalization, and the 90-day rate of mortality.

RESULTS

The final analysis included 58 patients in the preimplementation group and 34 patients in the postimplementation group. The rate of 30-day HF hospitalization was 10.3% in the preimplementation group and 0% in the postimplementation group. The rate of 30-day mortality was 3.4% in the preimplementation group and 0% in the postimplementation group. For the secondary endpoints, the number of interventions in 90 days was 3 vs 4, the 90-day rate of HF hospitalization was 22.4% vs 11.8%, and the rate of 90-day mortality was 6.9% vs 5.9% in the preimplementation vs postimplementation group, respectively.

CONCLUSION

Implementation of RPM in patients with acutely decompensated HF led to numerically lower 30-day and 90-day rates of HF hospitalization.

Outcomes of patients with elevated pulmonary artery systolic pressure on echocardiography due to chronic lung diseases

BACKGROUND

Pulmonary hypertension is associated with increased mortality, and lung diseases are the second most common cause of pulmonary hypertension. We aimed to evaluate the prognostic value of echocardiography in low-middle income countries where right heart catheterization is difficult to perform.

METHODS

This retrospective chart review study included adult patients hospitalized from June 2012 to May 2021, with a pulmonary artery systolic pressure (PASP) of ≥35 mmHg on echocardiography. The control arm consisted of patients with similar lung diseases who did not have an elevated PASP.

RESULTS

The study and control arm consisted of 128 patients each, with both groups having similar lung diseases. Obesity hypoventilation syndrome was the most common etiology of elevated PASP (28.1 %), followed by pulmonary embolism (20.3 %). The overall 1-year mortality of the study cohort, after diagnosis of elevated PASP, was 20.3 %. The control cohort with normal PASP had a 1-year mortality of 4.7 %. In the study cohort, patients with bronchiectasis had the highest cause-specific 1-year mortality (45.5 %). In the normal PASP cohort, the highest cause-specific 1-year mortality was observed in patients with interstitial lung disease (13.0 %). One-year hospital readmission was observed in 46.9 % and 33.6 % of patients in the study and control arms, respectively. On multivariate analysis, increased odds of 1-year mortality were observed in patients with elevated PASP, patients with 1-year hospital readmission, and in patients with interstitial lung disease or bronchiectasis.

CONCLUSION

Elevated PASP on echocardiography may be a prognostic factor for mortality in patients with chronic lung diseases.

Cardiac Abnormalities in Relation to the Disease Activity Index Among Systemic Lupus Erythematosus Patients in a Tertiary Hospital: A Cross-Sectional Study

BACKGROUND

 Systemic lupus erythematosus (SLE) is a multisystem autoimmune connective tissue disorder involving multiple organs and systems. Cardiovascular involvement in SLE patients is a major cause of morbidity and mortality. Although subclinical cardiac abnormalities exist among SLE patients, they are rarely screened for. Echocardiography has been demonstrated to be a useful tool for the early diagnosis of cardiac abnormalities in SLE patients, many of which are clinically silent. Early recognition of cardiovascular abnormalities is vital for the prompt initiation of the appropriate management. This study aims to determine the prevalence of various structural and functional cardiac abnormalities among SLE patients and to determine its association with the modified SLE Disease Activity Index 2000 (modified SLEDAI-2K).

METHODS

 The study was a cross-sectional study of SLE patients at the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana, from June to December 2021. The setting was the rheumatology outpatient clinic of the KBTH and included adult men and women, 18 years and above, diagnosed with SLE with no known cardiac abnormalities. The baseline demographic and clinical characteristics of the participants were determined. A detailed transthoracic echocardiogram was performed for all patients. The frequency of common cardiac pathologies was determined and compared between those with a high modified SLEDAI-2K and those with a low modified SLEDAI-2K.

RESULTS

 Ninety-nine SLE patients participated in the study with a mean age of 35.12 years. Females formed the majority (90.9%) of the participants. The mean age at diagnosis of SLE was 28.7 years and the mean disease duration was 4.6 years. All of the participants were on at least two disease-modifying medications. The mean modified SLEDAI-2K score was 9.1. Thirty-five percent (35%) of the patients had mild to moderately active disease and 39% had severely active disease. Sixty-six (66%) out of the severely active disease group had abnormal echocardiographic findings, while 28% of those with mild to moderate disease had abnormal echocardiographic findings. Echocardiographic abnormalities were found in 56 patients (47%), out of which 8.7% had valvular involvement, 15.7% had diastolic dysfunction, 5.2% had left ventricular hypertrophy (LVH), and 0.9% had left ventricular systolic dysfunction (LVSD). About 12% of the participants had pulmonary hypertension and 1% had pericardial involvement. The odds of echocardiographic abnormalities were 13.7 times higher in SLE patients with high disease activity compared to those with low disease activity (odds ratio (OR) = 13.714, 95% confidence interval (CI) = 3.804-49.442, p < 0.001). There was no significant association between cardiac abnormalities and SLE duration. No significant correlation between cardiac abnormalities and modified SLEDAI-2K score was found.  Conclusion: Cardiac abnormalities, especially left ventricular diastolic dysfunction (LVDD), valvular involvement, and pulmonary hypertension, are common in SLE patients. For SLE patients, especially those with active diseases, echocardiographic assessment should be considered in the management of SLE patients to enable early detection of cardiac abnormalities, early treatment, and thus a decrease in morbidity and mortality associated with cardiovascular involvement in SLE patients.

Epidemiology and outcomes of pulmonary hypertension in the cardiac intensive care unit

AIMS

Pulmonary hypertension (PH) has been consistently associated with adverse outcomes in hospitalized patients. Limited epidemiologic data exist regarding PH in the cardiac intensive care unit (CICU) population. Here, we describe the prevalence, aetiology, and outcomes of PH in the CICU.

METHODS AND RESULTS

Cardiac intensive care unit patients admitted from 2007 to 2018 who had right ventricular systolic pressure (RVSP) measured via transthoracic echocardiography near CICU admission were included. PH was defined as RVSP >35 mmHg, and moderate-to-severe PH as RVSP ≥50 mmHg. Predictors of in-hospital mortality were determined using multivariable logistic regression. Among 5042 patients (mean age 69.4 ± 14.8 years; 41% females), PH was present in 3085 (61%). The majority (68%) of patients with PH had left heart failure, and 29% had lung disease. In-hospital mortality occurred in 8.3% and was more frequent in patients with PH [10.9% vs. 4.2%, adjusted odds ratio (OR) 1.40, 95% confidence interval (CI) 1.03-1.92, P = 0.03], particularly patients with moderate-to-severe PH (14.4% vs. 6.2%, adjusted OR 1.65, 95% CI 1.27-2.14, P < 0.001). In-hospital mortality increased incrementally as a function of higher RVSP (adjusted 1.18 per 10 mmHg increase, 95% CI 1.09-1.28, P < 0.001). Patients with higher RVSP or moderate-to-severe PH had increased in-hospital mortality across admission diagnoses (all P < 0.05).

CONCLUSIONS

Pulmonary hypertension is very common in the CICU population and appears to be independently associated with a higher risk of death during hospitalization, although the strength of this association varies according to the underlying admission diagnosis. These data highlight the importance of PH in patients with cardiac critical illness.

Risk stratification in patients hospitalized for acute heart failure in Asian population

BACKGROUND

The AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score may be suboptimal in predicting long-term mortality in Asian patients with acute heart failure (AHF). We aimed to propose and validate a risk score incorporating easily available echocardiographic parameters to improve risk stratification in Asian patients with AHF.

METHODS

A total of 3537 patients hospitalized for AHF were enrolled and divided into generation and validation cohorts. Independent predictors of all-cause mortality were identified by Cox regression analysis and scored by hazard ratios to constitute the model. Model performance was validated and evaluated by receiver operating characteristic (ROC) curves and net reclassification improvement (NRI).

RESULTS

In the generation cohort of 1775 patients (74.3±13.0 years, 69.9% men), there were 870 deaths (49.0%) during a mean follow-up of 24.7±13.8 months. Age, anemia, estimated glomerular filtration rate <50 ml/min/1.73 m, hyperuricemia, left ventricular ejection fraction <50% and right ventricular systolic pressure (RVSP) >40 mmHg were independently related to mortality, which constituted "UR-HEARt" (U: uric acid, R: renal function, H: hemoglobin, E: ejection fraction of left ventricle, A: age, Rt: RVSP) score. Model performance was evaluated in the validation cohort (n = 1762), which outperformed AHEAD score by comparison of ROC curves in predicting all-cause mortality (area under curve [AUC] of UR-HEARt vs. AHEAD: 0.66 [95% CI 0.62-0.70] vs. 0.58 [95% CI 0.54-0.62]; p < 0.001), with NRI by 10.9% for all-cause mortality (p < 0.001) and 18.4% for cardiovascular death (p < 0.001).

CONCLUSION

UR-HEARt score, an easily accessible racial-specific risk score with integration of echocardiographic indices, improved risk stratification in Asian patients hospitalized for AHF.

Prognostic Significance of an Early Echocardiographic Evaluation of Right Ventricular Dimension and Function in Acute Heart Failure

OBJECTIVE

Sparse and contradictory data are available on the prognostic role of an early echocardiographic examination in patients with acute decompensated heart failure (ADHF). We planned a prospective study to illustrate which early echocardiographic parameter would be better related to prognosis in such patients.

METHODS

In a consecutive series of patients with ADHF with either reduced (n=209) or preserved (n=172) left ventricular ejection fraction (LVEF), a complete echocardiographic examination was performed within 12 hours of admission. The endpoint of the study was death or rehospitalization at 6 months from hospital discharge.

RESULTS

After 6 months from discharge, 73 died and 96 were rehospitalized due to cardiovascular causes. In multivariable analysis, a right ventricular end-diastolic diameter (RVEDD) >40 mm (P = .02), a tricuspid annular plane systolic excursion (TAPSE) <19 mm (P= .004), and an inferior vena cava diameter >22 mm (P = .02) were associated with 6-month events. LVEF and LV diastolic function were not predictive of events. Pulmonary artery systolic pressure (PASP) >45 mmHg and TAPSE/PASP <0.425 were associated with prognosis in univariate but not in multivariable analysis. Conversely, the TAPSE/RVEDD ratio (dichotomized at its median value of 0.461) was an independent predictor of outcome in multivariable analysis (P< .001).

CONCLUSIONS

In patients hospitalized for ADHF, early echocardiographic identification of right ventricular dilatation and dysfunction predicts a poor outcome better than LV systolic and/or diastolic dysfunction.

Characteristics of Patent Ductus Arteriosus in Congenital Rubella Syndrome

This study investigated the characteristics of congenital rubella syndrome (CRS)-associated cardiac complications, particularly patent ductus arteriosus (PDA). We reviewed the medical records of patients with CRS who were admitted to the Children's Hospital 1 in Vietnam between December 2010 and December 2012, and patients with CRS who underwent PDA transcatheter occlusion therapy at the cardiology department between December 2009 and December 2015. We compared the characteristics of PDA treated with transcatheter closure between children with CRS (CRS-PDA) and those without CRS (non-CRS-PDA) who underwent PDA transcatheter closure between July 2014 and December 2015. One-hundred-and-eight children with CRS were enrolled. Cardiac defects (99%), cataracts (72%), and hearing impairment (7%) were detected. Fifty CRS-PDA and 290 non-CRS-PDA patients were examined. CRS-PDA patients had smaller median birthweight (p < 0.001), more frequent pulmonary (p < 0.001) and aortic stenosis (p < 0.001), higher main pulmonary artery pressure, and higher aortic pressure in systole/diastole (p < 0.001 for each) than did non-CRS-PDA patients. The proportion of tubular-type PDA was higher in CRS-PDA patients (16%) than in non-CRS-PDA patients (3%) (p = 0.020). Tubular-type PDA was frequently seen in patients with CRS and accompanied by pulmonary/systemic hypertension and pulmonary/aortic stenosis; in these patients, more cautious device selection is needed for transcatheter PDA closure.

Improvement of Left Ventricular Ejection Fraction and Pulmonary Hypertension Are Significant Prognostic Factors in Heart Failure with Reduced Ejection Fraction Patients

BACKGROUND

We evaluated long-term prognosis according to improvement of pulmonary hypertension (PH) and left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF) and PH.

METHODS

We included all consecutive patients with HFrEF and PH who had a baseline and follow-up echocardiographic examinations from September 2011 to March 2017. PH was defined as maximal velocity of tricuspid regurgitation (TR Vmax) over 3.0 m/s, and LVEF improvement was defined as LVEF change ≥ 15% from the baseline echocardiography. Primary outcome was 5-year major adverse cardio-cerebrovascular events (MACCE).

RESULTS

We analyzed 271 patients. Mean LVEF was 28±8% and TR Vmax was 3.4±0.4 m/s. On follow-up, 183 (68%) showed improvement of LVEF, and 165 (61%) demonstrated improvement of PH. We classified patients into 4 groups according to improvement of PH and LVEF; group 1 (both improvement, 134 patients), group 2 (PH improvement only, 31 patients), group 3 (LVEF improvement only, 49 patients) and group 4 (no improvement, 57 patients). Group 4 had older age, higher incidence of myocardial infarction and aggravation of pre-existing HF. During the follow-up (31±20 months), 27% died and 40.8% experienced MACCE. Group 4 had the worst survival (HR=4.332, 95% CI=2.396-7.833, p<0.001), and group 3 had increased MACCE rate (HR=2.030, 95% CI=1.060-3.888, p=0.033) compared with group 1. Group 2 had similar long-term clinical events (HR=1.085, 95% CI=0.458-2.571, p=0.853) to group 1.

CONCLUSIONS

In patients with HFrEF and PH, persistence of PH and no LVEF improvement was associated with the worst long-term outcome.

Pulmonary Hypertension and Heart Failure: A Dangerous Liaison

Pulmonary hypertension (PH) is a common hemodynamic evolution of heart failure (HF) with preserved or reduced ejection fraction, responsible for congestion, symptoms worsening, exercise limitation, and negative outcome. In HF of any origin, PH develops in response to a passive backward pressure transmission as result of increased left atrial pressure. Sustained pressure injury and chronic venous congestion can trigger pulmonary vasoconstriction and vascular remodeling, leading to irreversible pulmonary vascular disease, right ventricular hypertrophy, and failure. In this article, the key determinants of this "dangerous liaison" are analyzed with some digressions on related "leitmotiv" at the horizon.

Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity

Background

The clinical relevance of non-invasively derived pulmonary arterial pressure (PAP) by Doppler echocardiography (DE) has been questioned in the past. However, transthoracic echocardiography is used as a cornerstone examination for patients with dyspnea and suspected pulmonary hypertension (PH). This study aimed to evaluate the prognostic value of non-invasive assessed PAP in a large population of patients with known or suspected cardiopulmonary disease.

Methods

The analyses are based on data of patients of a tertiary cardiology center that received right heart catheterization (RHC) as well as non-invasively assessed PAP by DE within five days, and includes serological and clinical parameters in a retrospective follow-up for up to eight years.

Results

Of 1,237 patients, clinical follow-up was possible in 1,038 patients who were included in the statistical analysis. The mean-follow up time was 1,002 days. The composite endpoint of heart transplantation (HTx) or death occurred in n = 308 patients. Elevated PAP measured non-invasively as well as invasively had significant prognostic impact (hazard ratio (HR) 2.32; 95% confidence interval (CI) 1.78–3.04; χ² = 37.9; p<0.001 versus HR 2.84; 95%CI 2.11–3.82; χ² = 51.9; p<0.001, respectively). By multivariate analysis, NYHA functional class, N-terminal pro-brain natriuretic peptide, cardiac troponin T, left ventricular ejection fraction, and right ventricular dysfunction remained independently predictive. Incremental prognostic information in a multimodal approach was highly relevant.

Conclusions

In this comprehensive study, elevated pulmonary arterial pressure measured by DE offers similar prognostic information on survival or need for HTx as right heart catheterization. Furthermore, the addition of functional capacity and serological biomarkers delivered incremental prognostic information.

Pulmonary Hypertension in Heart Failure Patients: Pathophysiology and Prognostic Implications

Pulmonary hypertension (PH) due to left heart disease (LHD), i.e., group 2 PH, is the most common reason for increased pressures in the pulmonary circuit. Although recent guidelines incorporate congenital heart disease in this classification, left-sided heart diseases of diastolic and systolic origin including valvular etiology are the vast majority. In these patients, an increased left-sided filling pressure triggers a multistage hemodynamic evolution that ends into right ventricular failure through an initial passive increase in pulmonary artery pressure complicated over time by pulmonary vasoconstriction, endothelial dysfunction, and remodeling of the small-resistance pulmonary arteries. Regardless of the underlying left heart pathology, when present, PH-LHD is associated with more severe symptoms, worse exercise tolerance, and outcome, especially when right ventricular dysfunction and failure are part of the picture. Compared with group 1 and other forms of pulmonary arterial hypertension, PH-LHD is more often seen in elderly patients with a higher prevalence of cardiovascular comorbidities and most, if not all, of the features of metabolic syndrome, especially in case of HF preserved ejection fraction. In this review, we provide an update on current knowledge and some potential challenges about the pathophysiology and established prognostic implications of group 2 PH in patients with HF of either preserved or reduced ejection fraction.

Incremental Prognostic Value of Conventional Echocardiography in Patients with Acutely Decompensated Heart Failure

BACKGROUND

Acutely decompensated heart failure (ADHF) presents high morbidity and mortality in spite of therapeutic advance. Identifying factors of worst prognosis is important to improve assistance during the hospital phase and follow-up after discharge. The use of echocardiography for diagnosis and therapeutic guidance has been of great utility in clinical practice. However, it is not clear if it could also be useful for risk determination and classification in patients with ADHF and if it is capable of adding prognostic value to a clinical score (OPTIMIZE-HF).

OBJECTIVE

To identify the echocardiographic variables with independent prognostic value and to test their incremental value to a clinical score.

METHODS

Prospective cohort of patients consecutively admitted between January 2013 and January 2015, with diagnosis of acutely decompensated heart failure, followed up to 60 days after discharge. Inclusion criteria were raised plasma level of NT-proBNP (> 450 pg/ml for patients under 50 years of age or NT-proBNP > 900 pg/ml for patients over 50 years of age) and at least one of the signs and symptoms: dyspnea at rest, low cardiac output or signs of right-sided HF. The primary outcome was the composite of death and readmission for decompensated heart failure within 60 days.

RESULTS

Study participants included 110 individuals with average age of 68 ± 16 years, 55% male. The most frequent causes of decompensation (51%) were transgression of the diet and irregular use of medication. Reduced ejection fraction (<40%) was present in 47% of cases, and the NT-proBNP median was 3947 (IIQ = 2370 to 7000). In multivariate analysis, out of the 16 echocardiographic variables studied, only pulmonary artery systolic pressure remained as an independent predictor, but it did not significantly increment the C-statistic of the OPTMIZE-HF score.

CONCLUSION

The addition of echocardiographic variables to the OPTIMIZE-HF score, with the exception of left ventricular ejection fraction, did not improve its prognostic accuracy concerning cardiovascular events (death or readmission) within 60 days.

Echocardiographic pulmonary artery pressure estimation and heart failure rehospitalization burden in patients with acute heart failure

Pulmonary hypertension (PH) is a strong predictor of mortality in patients with heart failure (HF). However, the relationship between PH, through echocardiographic pulmonary artery pressure (PASP) estimation, and the risk of HF rehospitalizations remains unclear.

METHODS

We prospectively included 2343 consecutive patients discharged for acute heart failure (AHF). PH was estimated by echocardiography through PASP determination during the index admission. Patients were categorized as follows across PASP: non-measurable, normal (≤35mmHg), mild (36-45mmHg), moderate (46-60mmHg), or severe PH (>60mmHg). Negative binomial regression method was used to evaluate the association between PASP and recurrent HF hospitalizations across preserved (HFpEF: ≥50%), mid-range (HFmrEF: 40-49%) and reduced ejection fraction (HFrEF: <40%).

RESULTS

Mean age of the cohort was 72.8±11.2years, 1187 (50.5%) were women, and 1252 (53.4%) and 410 (17.5%) showed HFpEF and HFmrEF, respectively. At a median (interquartile range) follow-up of 2.3 (0.8-4.5) years, we registered 1114 (47.6%) deaths, and 1834 HF-related rehospitalizations in 943 (40.2%) patients. After multivariable adjustment, and compared to patients with normal PASP, severe PH exhibited an independent higher risk of recurrent HF admissions only in HFpEF (IRR=1.66; 95% confidence interval (CI), 1.16-2.38; p=0.005), whereas in HFmrEF patients there was a non-significant trend to higher HF readmissions (IRR: 1.73; 95% CI, 0.85-3.55; p=0.132). Severe PH was not related with recurrent hospitalizations in HFrEF (IRR: 1.19; 95% CI, 0.66-2.14; p=0.553).

CONCLUSIONS

Echocardiography-derived PASP evaluated during an episode of AHF is related to HF readmission burden, particularly in those patients with HFpEF.

Pulmonary hypertension in heart failure with preserved ejection fraction

In heart failure with preserved ejection fraction (HFpEF), an entity that remains challenging and difficult to treat, the development of pulmonary hypertension (PH), via an increase in left atrial pressure, is the direct consequence of reduced relaxation and enhanced stiffness of the left ventricle and is now viewed as an important contributor to clinical worsening and increased mortality. PH becomes a relevant clinical phenotype in approximately 50% of patients with HFpEF and represents a true challenge in the clinical follow-up and management of these patients. Along with these epidemiologic insights, there has been increasing recognition of the pathophysiology of PH and its consequences on the right ventricle in patients with HFpEF. Novel and effective therapeutic interventions aimed at preventing and reversing PH are highly relevant in the attempt to modify the poor clinical trajectory and growing health care burden of HFpEF. Many theoretical rationales as well as progressively accumulating evidence support the usefulness of nitric oxide pathway-potentiating compounds in targeting the lung vasculature through phosphodiesterase 5 inhibitors or guanylate cyclase stimulators to produce vasodilation and potentially a biologic effect. These pharmacologic strategies may be clinically effective options for the treatment of PH in patients with HFpEF; however, large controlled trials are necessary to address definitively the safety, tolerability, and potential impact on morbidity and mortality. This review details the pathophysiologic process, prevalence, and consequences of HFpEF-associated PH and discusses current and emerging treatment strategies to prevent or treat this deleterious sequela when present.

Pathophysiology and clinical relevance of pulmonary remodelling in pulmonary hypertension due to left heart diseases

Pulmonary hypertension (PH) in left heart disease, classified as group II, is the most common form of PH that occurs in approximately 60% of cases of reduced and preserved left ventricular ejection fraction. Although relatively much is known about hemodynamic stages (passive or reactive) and their consequences on the right ventricle (RV) there is no consensus on the best hemodynamic definition of group II PH. In addition, the main pathways that lead to lung capillary injury and impaired biology of small artery remodelling processes are largely unknown. Typical lung manifestations of an increased pulmonary pressure and progressive RV-pulmonary circulation uncoupling are an abnormal alveolar capillary gas diffusion, impaired lung mechanics (restriction), and exercise ventilation inefficiency. Of several classes of pulmonary vasodilators currently clinically available, oral phosphodiesterase 5 inhibition, because of its strong selectivity for targeting the cyclic guanosine monophosphate pathway in the pulmonary circulation, is increasingly emerging as an attractive opportunity to reach hemodynamic benefits, reverse capillary injury, and RV remodelling, and improve functional capacity. Guanylate cyclase stimulators offer an additional intriguing opportunity but the lack of selectivity and systemic effects might preclude some of the anticipated benefits on the pulmonary circulation. Future trials will determine whether new routes of pharmacologic strategy aimed at targeting lung structural and vascular remodelling might affect morbidity and mortality in left heart disease populations. We believe that this therapeutic goal rather than a pure hemodynamic effect might ultimately emerge as an important challenge for the clinician.

Predictors of hospitalisations for heart failure and mortality in patients with pulmonary hypertension associated with left heart disease: a systematic review

OBJECTIVES

Left heart disease (LHD) is the main cause of pulmonary hypertension (PH), but little is known regarding the predictors of adverse outcome of PH associated with LHD (PH-LHD). We conducted a systematic review to investigate the predictors of hospitalisations for heart failure and mortality in patients with PH-LHD.

DESIGN

Systematic review.

DATA SOURCES

PubMed MEDLINE and SCOPUS from inception to August 2013 were searched, and citations identified via the ISI Web of Science.

STUDY SELECTION

Studies that reported on hospitalisation and/or mortality in patients with PH-LHD were included if the age of participants was greater than 18 years and PH was diagnosed using Doppler echocardiography and/or right heart catheterisation. Two reviewers independently selected studies, assessed their quality and extracted relevant data.

RESULTS

In all, 45 studies (38 from Europe and USA) were included among which 71.1% were of high quality. 39 studies were published between 2003 and 2013. The number of participants across studies ranged from 46 to 2385; the proportion of men from 21% to 91%; mean/median age from 63 to 82 years; and prevalence of PH from 7% to 83.3%. PH was consistently associated with increased mortality risk in all forms of LHD, except for aortic valve disease where findings were inconsistent. Six of the nine studies with data available on hospitalisations reported a significant adverse effect of PH on hospitalisation risk. Other predictors of adverse outcome were very broad and heterogeneous including right ventricular dysfunction, functional class, left ventricular function and presence of kidney disease.

CONCLUSIONS

PH is almost invariably associated with increased mortality risk in patients with LHD. However, effects on hospitalisation risk are yet to be fully characterised; while available evidence on the adverse effects of PH have been derived essentially from Caucasians.