Pulmonary Hypertension Severity in Heart Failure: Clinical Characteristics and Impact on Outcome

Left heart disease leading to increased left ventricular (LV) filling pressures is the most common cause of pulmonary hypertension (PH) and is referred to as isolated postcapillary PH (IpcPH). A proportion of these patients develop reactive PH, out of proportion to the increased venous pressures, because of vasoconstriction and vascular remodeling. This leads to pulmonary vascular disease with increased pulmonary vascular resistance, termed combined postcapillary and precapillary PH (CpcPH). Limited data exists on the characteristics and outcomes of patients with CpcPH. 1 Brittain EL Thenappan T Huston JH Agrawal V Lai YC Dixon D Ryan JJ Lewis EF Redfield MM Shah SJ Maron BA American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Lifestyle and Cardiometabolic Health; and Stroke CouncilElucidating the clinical implications and pathophysiology of pulmonary hypertension in heart failure with preserved ejection fraction: a call to action: a science advisory from the American Heart Association. Circulation. 2022; 146: e73-e88 Crossref PubMed Scopus (2) Google Scholar ,2 Riccardi M Pagnesi M Sciatti E Lombardi CM Inciardi RM Metra M Vizzardi E. Combined pre- and post-capillary pulmonary hypertension in left heart disease. Heart Fail Rev. 2023; 28: 137-148 Crossref PubMed Scopus (1) Google Scholar Generally, invasive measurements of left-sided pressures are required to differentiate IpcPH from CpcPH. Therefore, data on this phenomenon is limited to selected patients. 3 Miller WL Grill DE Borlaug BA. Clinical features, hemodynamics, and outcomes of pulmonary hypertension due to chronic heart failure with reduced ejection fraction: pulmonary hypertension and heart failure. JACC Heart Fail. 2013; 1: 290-299 Crossref PubMed Scopus (221) Google Scholar ,4 Thenappan T Shah SJ Gomberg-Maitland M Collander B Vallakati A Shroff P Rich S. Clinical characteristics of pulmonary hypertension in patients with heart failure and preserved ejection fraction. Circ Heart Fail. 2011; 4: 257-265 Crossref PubMed Scopus (216) Google Scholar Echocardiography can accurately assess pulmonary pressures. The ratio of the mitral valve E inflow and mitral annulus tissue Doppler e′ (E/e’ ratio), obtainable by echo, provides a good estimate of mean diastolic filling pressures in the LV, 5 Ommen SR Nishimura RA Appleton CP Miller FA Oh JK Redfield MM Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000; 102: 1788-1794 Crossref PubMed Google Scholar allowing to estimate the transpulmonary gradient (TPG) and differentiate IpcPH from CpcPH. We utilized a large echocardiography database with comprehensive clinical and outcome data to assess the characteristics and outcomes of patients with heart failure (HF) and PH, including patients with CpcPH.