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PA Pressures and Mortality in Adults With Reduced LVEF
Quick Takes
- Increased PA pressures, as determined by increased peak tricuspid regurgitant velocities on echocardiography, are associated with higher mortality in patients with reduced LVEF.
- The association is graded with higher mortality noted in groups with higher peak tricuspid regurgitant velocity.
Study Questions:
In patients with reduced left ventricular ejection fraction (LVEF), what is the association between elevated pulmonary artery pressures (PAPs) and all-cause mortality?
Methods:
This study used demographic and echocardiographic data from the National Echocardiography Database of Australia (NEDA) and linked it to mortality data from the National Death Index. At the time of analysis, the NEDA registry (January 2000 to June 2019) included over 1 million echocardiograms on >600,000 patients. Patients were included in the study if they were ≥18 years of age and had quantitative data available on peak tricuspid regurgitant velocity (TRV) and LVEF. Excluded were patients with an LVEF >50%, history of aortic or mitral valve replacement, and history of moderate or more aortic or mitral valve pathology. Peak TRV was used as a surrogate for PAPs and a marker for risk of pulmonary hypertension (PHT). Patients were categorized into four groups by peak TRV as low risk (<2.5 m/s), borderline risk (2.5-2.8 m/s), intermediate risk (2.9-3.4 m/s), and high risk (>3.4 m/s) PHT. All-cause mortality was assessed at 1 and 5 years.
Results:
A total of 23,675 patients were included in the analysis. The mean age of patients was 70 ± 15 years and 7,498 (31.7%) were female. For the four PHT risk categories, 8,801 (37.2%) were low risk, 7,061 (29.8%) were borderline risk, 5,676 (24.0%) were intermediate risk, and 2,137 (9.0%) were high risk. At baseline, patients with higher risk of PHT compared to low risk were older, had lower left and right ventricular (RV) systolic function, and had higher values for mitral E:e’ ratio, mitral E velocity, mitral E/A ratio, indexed left atrial volume, right atrial area, and rates of RV dilation.
Compared to the low risk PHT group, 1-year actuarial mortality increased with increasing risk of PHT by TRV (low risk: 13.3%, borderline risk: 20.5%, intermediate risk: 31.7%, high risk: 41.5%). Similar trends were seen with 5-year actuarial mortality (low risk: 43.8%, borderline risk: 56.7, intermediate risk: 73.0%, high risk: 81.4%). Compared to the low risk PHT group, the adjusted hazard ratio (HR) for mortality was 1.31 (95% confidence interval [CI], 1.23-138), HR 1.82 (95% CI, 1.72-1.93), and HR 2.38 (95% CI, 2.21-2.56) for the borderline, intermediate, and high risk PHT groups, respectively.
Conclusions:
In patients with reduced LVEF, elevated PAPs as estimated by peak TRV on echocardiography, were associated with increased all-cause mortality.
Perspective:
In patients with reduced LVEF, it is common to have findings of elevated PAPs and PHT. This study adds to literature by providing confirmation in a large clinical cohort of patients that there is a graded and negative impact of increased PAPs on patient survival. Interestingly, this study also highlights an increased mortality risk even with patients classified as having borderline elevations in peak TRV, suggesting that more attention needs to be paid to this subgroup. Important limitations to this study to keep in mind are the lack of granular patient-level data to assess for additional confounders, lack of quantitative RV data, heterogeneity of the patient population, and imperfect use of TRV to diagnose and grade PHT. Additionally, future work will need to assess if targeted therapies to reduce PAPs in high-risk patients can alter prognosis.
Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound, Heart Failure and Cardiomyopathies
Keywords: Echocardiography, Heart Failure, Reduced Ejection Fraction
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