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Validation of Post-Capillary PH Definition in HF
Quick Takes
- This multicenter prospective PH-HF study externally validates the prognostic value of the 2022 ESC/ERS definition of post-capillary pulmonary hypertension (pcPH), since pcPH had worse outcomes compared with HF patients without pcPH.
- Overall, this study highlights the incremental prognostic value of the new definition among patients with HF since event-free survival starts decreasing as soon as mean pulmonary artery pressure is above 20 mm Hg and even more so when pulmonary vascular resistance is above 2 WU.
Study Questions:
What is the impact and prognostic value of the new 2022 European guideline definition of post-capillary pulmonary hypertension (pcPH) in heart failure (HF), which lowered the level of mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR)?
Methods:
The investigators enrolled stable left HF patients with the need for right heart catheterization from 2010 to 2018 and prospectively followed up in this multicenter study. The impact of the successive pcPH definitions on pcPH prevalence and subgroup (i.e., isolated [IpcPH] vs. combined pcPH [CpcPH]) was evaluated. Multivariable Cox regression analysis was used to assess the prognostic value of mPAP and PVR on all-cause death or hospitalization for HF (primary outcome).
Results:
Included were 662 HF patients (median age 63 years, 60% male). Lowering mPAP from 25 to 20 mm Hg resulted in a +10% increase in pcPH prevalence, whereas lowering PVR from 3 to 2 resulted in a +60% increase in CpcPH prevalence (with significant net reclassification improvement for the primary outcome). In multivariable analysis, both mPAP and PVR remained associated with the primary outcome (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00–1.03; p = 0.01; HR, 1.07; 95% CI, 1.00–1.14; p = 0.03). The best PVR threshold associated with the primary outcome was approximately 2.2 WU. Using the 2022 definition, pcPH patients had worse survival compared with HF patients without pcPH (log-rank, p = 0.02) as well as CpcPH compared with IpcPH (log-rank, p = 0.003).
Conclusions:
The authors report that this study emphasizes the impact of the new pcPH definition on CpcPH prevalence and validates the prognostic value of mPAP >20 mm Hg and PVR >2 WU among HF patients.
Perspective:
This multicenter prospective PH-HF study externally validates the prognostic value of the 2022 European Society of Cardiology/European Respiratory Society (ESC/ERS) definition of pcPH, since pcPH had worse outcomes compared with HF patients without pcPH. Furthermore, patients with CpcPH had a worse event-free survival compared with IpcPH, reinforcing the prognostic value of PVR >2 WU. Overall, this study highlights the incremental prognostic value of the new definition among patients with HF since event-free survival starts decreasing as soon as mPAP is above 20 mm Hg and even more so when PVR is above 2 WU. Of note, PH–HFpEF had a better prognosis compared with PH–HFrEF using this new definition. Additional prospective studies are indicated to assess whether these thresholds also have a therapeutic impact.
Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Acute Heart Failure, Pulmonary Hypertension, Hypertension
Keywords: Heart Failure, Hypertension, Pulmonary
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