Invasive and non-invasive determinants of pulmonary hypertension in patients with chronic heart failure

Background: In patients with chronic heart failure, pulmonary hypertension is an important predictive marker of adverse outcome. Its invasive and non- invasive determinants have not been evaluated. Objective: This study was performed to evaluate hemodynamic determinants of pulmonary hypertension in chronic heart failure and to compare the predict ive value of Doppler indices with that of invasively measured hemodynamic i ndices. Methods: Right heart catheterization and transthoracic echo-Doppler were si multaneously performed in 259 consecutive patients with chronic heart failu re (ejection fraction 24% +/- 7%) who were in sinus rhythm and receiving op timized medical therapy. Systolic pulmonary artery pressure (sPAP), cardiac index transpulmonary gradient pressure, and pulmonary wedge pressure (PWP) were measured invasively. Left atrial and,ventricular systolic and diastol ic volumes, the ratio of maximal early to late diastolic filling velocities (E/A ratio), deceleration time (DT) and atrial filling fraction (AFF) of t ransmitral flow, systolic fraction of forward pulmonary venous flow (SFpvf) , and mitral regurgitation were quantified by echo-Doppler. Results: Patients with pulmonary hypertension had greater left atrial systo lic and diastolic dysfunction, more left ventricular diastolic abnormalitie s, and greater hemodynamic impairment. The correlations between systolic le ft ventricular indices, mitral regurgitation, and sPAP were generally poor. Among invasive and non-invasive measurements, PWP (r = 0.89, p < 0.0001) a nd SFpvf (r = -0.68, p < 0.0001) showed the strongest correlation with sPAP . When we compared all patients with those without mitral regurgitation, th e correlations between E/A ratio (r = 0.56 vs r = 0.74, p < 0.002), SFpvf ( r = -0.68 vs r = -0.84, p < 0.03), and systolic pulmonary artery pressure w ere significantly stronger. Multivariate analysis revealed that PWP was the strongest invasive independent predictor of systolic pulmonary artery pres sure in patients with (R-2 = 0.87, p < 0.0001) and without (R-2 = 0.90,p < 0.0001) mitral regurgitation, A PWP greater than or equal to 18 mm Hg (odds ratio [95% CL], 142 (41-570) was strongly associated with systolic pulmona ry hypertension. Among non-invasive variables DT, SFpvf, and AFF were ident ified as independent predictors of sPAP in patients with (R-2 = 0.56, p < 0 .0001) and without (R-2 = 0.78, p < 0.0001) mitral regurgitation. A DT < 13 0 (odds ratio [95% CLI, 3.5 (1.3-8.5), SFfvp < 40% (odds ratio [95% CL], 33 3 (41-1,007), and AFF < 30% (odds ratio [95% CL], 2 (1.3-7) most strongly p redicted systolic pulmonary hypertension. Conclusions: The results of this study indicate that in patients with chron ic heart failure, venous pulmonary congestion is an important determinant o f systolic pulmonary artery hypertension. Hemodynamic and Doppler determina nts showed similar predictive power in identifying systolic pulmonary arter y hypertension.