Elevated Pulmonary Artery Pressure by Doppler Echocardiography Predicts Hospitalization for Heart Failure and Mortality in Ambulatory Stable Coronary Artery Disease

Department of Medicine, Division of Cardiology, University of California, San Francisco, California, USA.
Journal of the American College of Cardiology (Impact Factor: 15.34). 02/2007; 49(1):43-9. DOI: 10.1016/j.jacc.2006.04.108
Source: PubMed

ABSTRACT We compared the predictive ability of tricuspid regurgitation (TR) and end-diastolic pulmonary regurgitation (EDPR) gradients in outpatients with coronary artery disease.
The TR and EDPR gradients, in conjunction with right atrial pressure, provide Doppler estimates of pulmonary artery systolic and diastolic pressures. We hypothesized that increases in TR or EDPR gradients in stable coronary artery disease would predict heart failure (HF) hospitalization or cardiovascular (CV) death.
We measured TR and EDPR gradients in 717 adults with completed outcome adjudications who were recruited for the Heart and Soul Study. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for HF hospitalization, CV death, all-cause death, and the combined end point. Multivariate adjustments were made for age, gender, race, history of CV or pulmonary disease, functional class, and left ventricular ejection fraction.
There were 63 HF hospitalizations, 19 CV deaths, and 86 all-cause deaths at the 3-year follow-up. There were 466 measurable EDPR gradients and 573 measurable TR gradients. Age-adjusted ORs for EDPR >5 mm Hg predicted HF hospitalization (2.7, 95% CI 1.3 to 5.5, p = 0.006), all-cause death (2.5, 95% CI 1.4 to 4.4, p = 0.002), and HF hospitalization or CV death (2.7, 95% CI 1.4 to 5.2, p = 0.004). Age-adjusted OR for TR >30 mm Hg predicted HF hospitalization (3.4, 95% CI 1.9 to 6.2, p < 0.0001) and HF hospitalization or CV death (3.0, 95% CI 1.7 to 5.3, p = 0.0001). Multivariate adjusted OR per 5-mm Hg incremental increases in EDPR predicted HF hospitalization or CV death (1.9, 95% CI 1.01 to 3.6, p = 0.046) and all-cause death (1.7, 95% CI 1.05 to 2.8, p = 0.03). Multivariate adjusted OR per 10-mm Hg incremental increases in TR predicted HF hospitalization or CV death (1.6, 95% CI 1.1 to 2.4, p = 0.008).
Increases in EDPR or TR gradients predict HF hospitalization or CV death among ambulatory adults with coronary artery disease.

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    ABSTRACT: Background-Although elevated pulmonary artery systolic pressure (PASP) is associated with heart failure (HF), whether PASP measurement can help predict future HF admissions is not known, especially in African Americans who are at increased risk for HF. We hypothesized that elevated PASP is associated with increased risk of HF admission and improves HF prediction in African American population. Methods and Results-We conducted a longitudinal analysis using the Jackson Heart Study cohort (n=3125; 32.2% men) with baseline echocardiography-derived PASP and follow-up for HF admissions. Hazard ratio for HF admission was estimated using Cox proportional hazard model adjusted for variables in the Atherosclerosis Risk in Community (ARIC) HF prediction model. During a median follow-up of 3.46 years, 3.42% of the cohort was admitted for HF. Subjects with HF had a higher PASP (35.6 +/- 11.4 versus 27.6 +/- 6.9 mm Hg; P<0.001). The hazard of HF admission increased with higher baseline PASP (adjusted hazard ratio per 10 mm Hg increase in PASP: 2.03; 95% confidence interval, 1.67-2.48; adjusted hazard ratio for highest [>= 33 mm Hg] versus lowest quartile [<24 mm Hg] of PASP: 2.69; 95% confidence interval, 1.43-5.06) and remained significant irrespective of history of HF or preserved/reduced ejection fraction. Addition of PASP to the ARIC model resulted in a significant improvement in model discrimination (area under the curve=0.82 before versus 0.84 after; P=0.03) and improved net reclassification index (11-15%) using PASP as a continuous or dichotomous (cutoff=33 mm Hg) variable. Conclusions-Elevated PASP predicts HF admissions in African Americans and may aid in early identification of at-risk subjects for aggressive risk factor modification.
    Circulation Heart Failure 06/2014; 7(4). DOI:10.1161/CIRCHEARTFAILURE.114.001366 · 5.95 Impact Factor
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    ABSTRACT: -Doppler-echocardiography (D-E) provides quantitative imaging of systolic and diastolic left ventricular (LV) function, functional mitral regurgitation (FMR), and pulmonary hypertension (PH), in patients with LV systolic dysfunction (LVSD). Whether PH is linked to survival independently of LV features and FMR in symptomatic and asymptomatic patients is unknown. -Patients with LVEF ≤ 40% and quantitative D-E assessment of FMR and PH were studied. Patients were frequency matched for those with D-E estimated pulmonary systolic pressure (PSP) ≥ 45 mmHg (N=692) and those without PH (N=692, PSP <45mmHg)) for age, gender, LVEF, and quantified FMR severity, and analyzed for long-term survival after diagnosis. During follow-up (median 8.9 years), 885 deaths (63.5%) occurred with PH being associated with higher 5-year mortality: 51 ± 2% vs 37 ± 2%, p < 0.001. In multivariate analysis, PH demonstrated increased mortality risk independent of age, gender, severity of diastolic and systolic LV dysfunction, FMR, co-morbidities, and symptom (HR 1.34, 95% CL 1.17-1.53, p < 0.001). Subgroup analysis, stratified by symptoms, degree of FMR, and severity of LV dysfunction demonstrated that PH was associated with excess mortality in all subgroups. -In this large cohort of LVSD patients, in whom FMR and LV characteristics were quantified and matched between those with and without PH, the presence of PH was an independent factor for excess mortality, and not a surrogate for the severity of LVSD or FMR. In asymptomatic or symptomatic patients with or without FMR, PH is a critical marker for poor outcomes.
    Circulation Cardiovascular Imaging 01/2014; 7(2). DOI:10.1161/CIRCIMAGING.113.001184 · 6.75 Impact Factor
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    ABSTRACT: 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.
    BMJ Open 07/2014; 4(7):e004843. DOI:10.1136/bmjopen-2014-004843 · 2.06 Impact Factor


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