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

ArticleinJournal of the American College of Cardiology 49(1):43-9 · February 2007with6 Reads
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.
    • "The development of PH in patients with LHD is associated with poor prognosis. PH has been shown to be an independent predictor of mortality in patients with a range of cardiac dysfunctions, including those with heart failure [23, 31], dilated cardiomyopathy [28], stable coronary artery disease [37] and following acute myocardial infarction [38] . In the communitybased study of patients with heart failure by BURSI et al. [9], there was a strong positive association between systolic Ppa and overall and cardiac mortality that was independent of age, sex, comorbidities, LV ejection fraction and diastolic function (fig. "
    [Show abstract] [Hide abstract] ABSTRACT: Pulmonary hypertension (PH) is a frequent complication of left heart disease arising from a wide range of cardiac disorders. In the clinical classification, PH associated with left heart disease is classified as Group 2, which includes left heart systolic dysfunction, left heart diastolic dysfunction and left heart valvular disease. In the past, rheumatic mitral valve disease was the most common cause of PH in left heart disease; however, today it is more likely to be associated with hypertensive and/or ischaemic heart disease. As the incidence of these conditions is increasing, the number of patients presenting with PH is also increasing and, today, left heart disease represents the most frequent cause of PH. The development of PH in patients with left heart disease is associated with poor prognosis. However, despite the increasingly large number of patients affected and the impact of PH on outcome, there are currently no specific treatment options for these patients. This review gives an overview of the pathophysiology and epidemiology of PH associated with left heart disease, and discusses the challenges associated with its management and treatment.
    Full-text · Article · Dec 2012
    • "Therefore, while the order of examinations to be undertaken in subjects with incidental PH on echocardiography remains unclear, screening for respiratory disorders should be featured prominently in any diagnostic strategy for raised PASP on TTE. In a study involving patients with established heart disease, increased TR gradient was associated with a significant increase in heart failure hospitalizations and cardiovascular mortality.[21] Our study differs in the absence of pre-existing heart disease, and the majority of subjects were not known to have heart disease, or LVSD. "
    [Show abstract] [Hide abstract] ABSTRACT: Pulmonary arterial systolic pressure (PASP) can be estimated with transthoracic echocardiography. However, the significance of raised PASP on routine echocardiography is uncertain. In this study, we evaluated the mortality and hospitalization rates of subjects with raised PASP in a cohort of patients referred directly by their general practitioners for routine outpatient (open access) echocardiography for further analysis of suspected heart failure. A total of 485 subjects were referred for open access echocardiography at our hospital in 2002. A cohort of 209/485 (43%) consecutive subjects with measurable tricuspid regurgitation were followed for a minimum of five years investigating hospitalization rates and survival. Some 62 of 209 (30%) subjects had pulmonary hypertension (PH). Subjects with PH were significantly more likely to have four or more hospital admissions (22% vs. 8%; P < 0.01) and > 30 days of cumulative hospital stay over five years (29% vs. 13%; P < 0.01). PH was significantly associated with mortality (P = 0.003), while moderate to severe PH was an independent predictor of mortality (hazard ratio: 4.31; 95% confidence interval (95% CI): 1.51-12.30). Records from the Office of National Statistics revealed that subjects with PH were more likely to have chronic lung diseases recorded as immediate or contributory causes of death (50% vs. 14%; P < 0.05). PASP ≥ 36 mmHg on routine echocardiography is associated with recurrent hospital admissions, prolonged hospitalizations and increased cause of mortality. Therefore, the diagnosis of PH on echocardiography deserves further clinical evaluation, with future studies designed at defining a suitable diagnostic strategy.
    Full-text · Article · Dec 2012
    • "Abnormal dynamics in this filling phase in either ventricle may suggest valve dysfunction, but could also suggest a wider problem with the circulation, for example pulmonary embolism [3]. Pulmonary embolism is often characterised by tricuspid regurgitation and causes the secondary effect of increased volume in the atrium and/or ventricle [3]. Thus, significant research concentrates on the understanding of detailed flow dynamics and pressure around the valves and atria. "
    [Show abstract] [Hide abstract] ABSTRACT: Located between the left atrium and the left ventricle, the mitral valve controls flow between these two cardiac chambers. Mitral valve dysfunction is a major cause of cardiac dysfunction and its dynamics are little known. A simple non-linear rotational spring model is developed and implemented to capture the dynamics of the mitral valve. A measured pressure difference curve was used as the input into the model, which represents an applied torque to the anatomical valve chords. A range of mechanical model hysteresis states were investigated to find a model that best matches reported animal data of chord movement during a heartbeat. The study is limited by the use of one dataset found in the literature due to the highly invasive nature of getting this data. However, results clearly highlight fundamental physiological issues, such as the damping and chord stiffness changing within one cardiac cycle, that would be directly represented in any mitral valve model and affect behaviour in dysfunction. Very good correlation was achieved between modeled and experimental valve angle with 1-10% absolute error in the best case, indicating good promise for future simulation of cardiac valvular dysfunction, such as mitral regurgitation or stenosis. In particular, the model provides a pathway to capturing these dysfunctions in terms of modeled stiffness or elastance that can be directly related to anatomical, structural defects and dysfunction.
    Full-text · Article · Nov 2011
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