Prevalence and prognostic significance of pulmonary hypertension in adults with left ventricular diastolic dysfunction

Seshika Ratwatte; David Playford; Geoff Strange; David S Celermajer; Simon Stewart

doi:10.1136/openhrt-2024-003049

Prevalence and prognostic significance of pulmonary hypertension in adults with left ventricular diastolic dysfunction

Open Heart. 2024 Dec 3;11(2):e003049. doi: 10.1136/openhrt-2024-003049.

Authors

Seshika Ratwatte^{1

2}, David Playford³, Geoff Strange^{3

4}, David S Celermajer^{1

2

4}, Simon Stewart^{5

6}

Affiliations

¹ Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
² Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
³ School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia.
⁴ Heart Research Institute Ltd, Newtown, New South Wales, Australia.
⁵ School of Medicine, The University of Notre Dame, Fremantle, Western Australia, Australia [email protected].
⁶ University of Glasgow, School of Medicine, Dentistry and Nursing, Glasgow, UK.

Abstract

Aims: Pulmonary hypertension (PHT) appears to be very common in heart failure with preserved ejection fraction but details on its prevalence, severity and prognostic implications have not been well defined. We, therefore, aimed to document PHT and its impact on mortality among adults with left ventricular (LV) diastolic dysfunction (LVDD).

Methods: We analysed the profile and outcomes of 16 058 adults with LVDD (and with preserved LV ejection fraction, >50%) from the National Echocardiography Database of Australia. Subjects were classified according to their peak tricuspid regurgitation velocity (TRV), reflecting PHT risk, and we then evaluated the relationship between conventional thresholds of increasing risk of PHT and subsequent mortality, during median follow-up of 3.1 (IQR 1.6-5.2) years.

Results: Mean age was 73±12 years and 9216 (57.4%) were female. Overall, 2611 (16.3%) had normal TRV levels (<2.5 m/s) indicative of no PHT, compared with 3471 (21.6%), 8450 (52.6%) and 1526 (9.5%) with TRV levels indicative of borderline (2.5-2.8 m/s), intermediate (2.9-3.4 m/s) and high-risk for PHT (>3.4 m/s). The 1-year and 5-year actuarial mortality (1701/1546 and 4232/8445 deaths, respectively) increased from 6.5% and 34.0% to 27.7% and 78.5%, respectively (p<0.0001), from normal to severely elevated TRV. Adjusted risk (HR) of mortality increased 1.28-fold (95% CI 1.15 to 1.41), 1.51-fold (95% CI 1.38 to 1.65) and 3.47-fold (95% CI 3.13 to 3.85) in those with borderline, intermediate and high risk of PHT versus normal TRV. This observation persisted when excluding atrial fibrillation cases, and when male and female cohorts were assessed separately. Mortality rates increased perceptibly at the second decile distribution of TRV (2.37-2.55 m/s) with a marked increase in mortality from the fifth decile (2.91-3.00 m/s) upwards.

Conclusion: We demonstrate the negative prognostic impact of elevated TRV levels in many adults with isolated LVDD. A threshold of increased mortality was observed at TRV levels equivalent to 'borderline risk' of PHT.

Trial registration number: ACTRN12617001387314.

Keywords: Echocardiography; Heart Failure, Diastolic; Hypertension, Pulmonary.

Publication types

Multicenter Study

MeSH terms

Aged
Aged, 80 and over
Australia / epidemiology
Diastole
Female
Follow-Up Studies
Humans
Hypertension, Pulmonary* / diagnosis
Hypertension, Pulmonary* / epidemiology
Hypertension, Pulmonary* / mortality
Hypertension, Pulmonary* / physiopathology
Male
Middle Aged
Prevalence
Prognosis
Retrospective Studies
Risk Assessment / methods
Risk Factors
Stroke Volume / physiology
Survival Rate / trends
Time Factors
Ventricular Dysfunction, Left* / diagnosis
Ventricular Dysfunction, Left* / epidemiology
Ventricular Dysfunction, Left* / mortality
Ventricular Dysfunction, Left* / physiopathology
Ventricular Function, Left / physiology