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Original Investigation
April 2018

Association Between Hemodynamic Markers of Pulmonary Hypertension and Outcomes in Heart Failure With Preserved Ejection Fraction

Author Affiliations
  • 1Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania
  • 2Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Analytics Center, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 4Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 5Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 6University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
JAMA Cardiol. 2018;3(4):298-306. doi:10.1001/jamacardio.2018.0128
Key Points

Question  What are the hemodynamic characteristics and outcomes for pulmonary hypertension associated with heart failure with preserved ejection fraction?

Findings  In a cohort study of 10 023 individuals undergoing right heart catheterization at a single center between 2005 and 2012, 2587 (25.8%) had PH-HFpEF. Mortality was 23.6% at 1 year and 48.2% at 5 years, and cardiac hospitalizations occurred in 28.1% at 1 year and 47.4% at 5 years.

Meaning  Pulmonary hypertension associated with heart failure with preserved ejection fraction is common in individuals undergoing right heart catheterization and is associated with poor outcomes; this heart failure with preserved ejection fraction phenotype requires further study and new therapies.

Abstract

Importance  Heart failure with preserved ejection fraction (HFpEF) is highly prevalent, yet there are no specific therapies, possibly due to phenotypic heterogeneity. The development of pulmonary hypertension (PH) in patients with HFpEF is considered a high-risk phenotype in need of targeted therapies, but there have been limited hemodynamic and outcomes data.

Objective  To identify the hemodynamic characteristics and outcomes of PH-HFpEF.

Design, Setting, and Participants  Cohort study of participants who had a right heart catheterization from January 2005 to September 2012 (median [interquartile range] follow-up time, 1578 [554-2513] days) were analyzed. Hemodynamic catheterization data was linked to the clinical data repository of all inpatient and outpatient encounters across a health system. Single tertiary referral center for heart failure and PH within a large health care network using a common clinical data repository was studied. There were 19 262 procedures in 10 023 participants.

Exposures  Participants were classified as having no PH, precapillary PH, or PH in the setting of left heart disease (reduced or preserved ejection fraction). Pulmonary hypertension associated with HFpEF was defined as mean pulmonary artery pressure of 25 mm Hg or more, pulmonary artery wedge pressure of 15 mm Hg or more, and left ventricular ejection fraction of 45% or more. Pulmonary hypertension severity was quantified by the hemodynamic parameters transpulmonary gradient, pulmonary vascular resistance, and diastolic pulmonary gradient.

Main Outcomes and Measures  The primary outcome was time to all-cause mortality. Secondary outcomes were time to acute hospitalization and cardiovascular hospitalization.

Results  The mean (SD) of all study individuals was 65 (38) years. Of 10 023 individuals, 2587 (25.8%) had PH-HFpEF. Mortality was 23.6% at 1 year and 48.2% at 5 years. Cardiac hospitalizations occurred in 28.1% at 1 year and 47.4% at 5 years. The frequency of precapillary PH using clinically defined cut-offs for transpulmonary gradient (>12 mm Hg), pulmonary vascular resistance (3 Woods units), and diastolic pulmonary gradient (≥7 mm Hg) were 12.6%, 8.8%, and 3.5%, respectively. Transpulmonary gradient, pulmonary vascular resistance, and diastolic pressure gradient were predictive of mortality and cardiac hospitalizations.

Conclusions and Relevance  In a large cohort referred for invasive hemodynamic assessment, PH-HFpEF was common. Transpulmonary gradient, pulmonary vascular resistance, and diastolic pulmonary gradient are all associated with mortality and cardiac hospitalizations.

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