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

Department of Medicine, University of California, San Francisco, San Francisco, California, United States
Journal of the American College of Cardiology (Impact Factor: 16.5). 02/2007; 49(1):43-9. DOI: 10.1016/j.jacc.2006.04.108
Source: PubMed


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.

Full-text preview

Available from:
  • Source
    • "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 · Journal of Geriatric Cardiology
  • Source
    • "Tricuspid valve regurgitation (TR) can be detected in only 39–86% of patients and in only 44–96% of these cases does the regurgitation produce enough signal for pressure measurement to be made possible [4]. Detecting a good signal from pulmonary valve regurgitation also requires technical competence but has approximately the same yield as TR signals [11]. Furthermore, PAP measurement without flow information can be misleading especially in cases with elevated PAP due to high cardiac output but normal pulmonary vascular resistance (PVR). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Pulmonary arterial hypertension (PAH) is a life-threatening condition characterized by progressive elevation in pulmonary artery pressure (PAP) and total pulmonary vascular resistance (TPVR). Recent advances in imaging techniques have allowed the development of new echocardiographic parameters to evaluate disease progression. However, there are no reports comparing the diagnostic performance of these non-invasive parameters to each other and to invasive measurements. Therefore, we investigated the diagnostic yield of echocardiographically derived TPVR and Doppler parameters of PAP in screening and measuring the severity of PAH in a rat model. Serial echocardiographic and invasive measurements were performed at baseline, 21 and 35 days after monocrotaline-induction of PAH. The most challenging echocardiographic derived TPVR measurement had good correlation with the invasive measurement (r = 0.92, P < 0.001) but also more simple and novel parameters of TPVR were found to be useful although the non-invasive TPVR measurement was feasible in only 29% of the studies due to lack of sufficient tricuspid valve regurgitation. However, echocardiographic measures of PAP, pulmonary artery flow acceleration time (PAAT) and deceleration (PAD), were measurable in all animals, and correlated with invasive PAP (r = -0.74 and r = 0.75, P < 0.001 for both). Right ventricular thickness and area correlated with invasive PAP (r = 0.59 and r = 0.64, P < 0.001 for both). Observer variability of the invasive and non-invasive parameters was low except in tissue-Doppler derived isovolumetric relaxation time. These non-invasive parameters may be used to replace invasive measurements in detecting successful disease induction and to complement invasive data in the evaluation of PAH severity in a rat model.
    Full-text · Article · Feb 2010 · The international journal of cardiovascular imaging
  • [Show abstract] [Hide abstract]
    ABSTRACT: Aluminum toxicity is a very important factor limiting crop productivity on acid soils. Early effects of aluminum toxicity comprise inhibition of cell division and effects on root elongation. The plasma membrane can be the primary target of aluminum toxicity and thus, vital staining techniques could be a powerful tool in determining effects of metal stress on the plasma membrane. In this paper. we discuss the effects of Al on growth and membrane integrity by staining root tips with a mixture of fluorescein diacetate and propidium iodide. The results show a good correlation between results from growth measurement and the vital staining. From the comparison of the luminosity patterns generated by vital staining it is easy to determine Al-resistant varieties, revealing this technique as a powerful and fast method for determining tolerance to Al in different varieties.
    No preview · Article · Jan 2004 · Journal of Plant Physiology
Show more