Clinical Characteristics, Prevalence And Prognosis Of Pulmonary Hypertension Caused By Left Heart Failur

PART Ⅰ Characteristics,prevalence,and survival of pulmonary hypertension associated with left heart failure:Insights from a national multicenter prospective registry studyBackground:Pulmonary hypertension associated with left heart failure(PH-LHF)is a subgroup of pulmonary hypertension(PH)associated with left heart disease(Group 2 PH),and PH-LHF is currently the most common form of PH encountered in clinical practice.However,the prevalence of PH in patients with left heart failure(LHF)is wide variability among different studies.This is mainly due to the nonuniform methodology of diagnostic testing(echocardiography or hemodynamic measures during right heart catheterization(RHC))and the different cutoff values to define PH.Currently,studies focusing on PH-LHF in China are very limited,and long-term survival data for PH-LHF are lacking.Our understanding of PH-LHF mainly comes from foreign studies.Therefore,it is urgent for China to establish a database of PHLHF patients diagnosed by RHC,conduct a multicenter registry study,and investigate the clinical and epidemiological characteristics of PH-LHF.Objectives:This study aimed to describe the characteristics,prevalence,and survival of PH-LHF in China.Methods:A retrospective analysis of a national multicenter prospective registry study of LHF patients who underwent RHC between January 2013 and November 2016 was performed.Baseline information was collected for each enrolled patient,including medical history,demographic data,laboratory tests,medication,echocardiography,and RHC parameters.Patients were classified into the PH-LHF and nonPH-LHF groups according to hemodynamic characteristics.Follow-ups were performed every 6 months±2 weeks for PH-LHF group patients.The endpoint was all-cause mortality.Results:A total of 480 patients from 11 tertiary hospitals in China with LHF were enrolled,with 252(52.5%)having PH-LHF.Among 252 PH-LHF patients,the mean age was 63.5±12.3,and 70.6%of patients presenting HFpEF,the most common underlying diseases were coronary artery disease.The median mPAP measured by RHC in PH-LHF patients was 29 mmHg(interquartile interval:26-34 mmHg),and 78.6%of PH-LHF patients had mPAP between 21 mmHg and 35 mmHg.The PHLHF group had a higher right anteroposterior ventricular diameter(RVAPD)and a higher percentage of NYHA FC Ⅲ/Ⅳ than the nonPH-LHF group.The clinical characteristics of the PH-LHF group,including age,type of LHF,and underlying diseases,were similar to the nonPH-LHF group.Multivariable logistic regression analysis showed that RVAPD(OR:1.514,95%CI:1.021-2.296,P=0.045)and NYHAFC(OR:1.626,95%CI:1.026-2.576,P=0.039)are independent predictive factors for PH in LHF patients.The median follow-up for the PH-LHF cohort was 84 months(95%CI:78.5-89.5),and 81 patients(32.1%)died during follow-up.The 1-,3-,5-,and 8-year survival rates of PH-LHF patients were 95.2%,77.8%,68.7%,and 63.3%,respectively.Conclusions:The clinical characteristics of PH-LHF patients were similar to LHF but had a more severely dilated right ventricle,and a higher percentage of NYHA FCⅢ/Ⅳ.Most PH-LHF patients had mildly increased mPAP.PH is commonly identified in patients with LHF in China,and about half of the patients with LHF are complicated by PH.The long-term survival rate of PH-LHF is low and the prognosis is poor.PART Ⅱ Prognosis of pulmonary hypertension associated with left heart failure with mPAP between 21 and 24 mmHg:A 3-year survivorship analysis of a national multicenter prospective registry studyBackground:Patients with left heart failure(LHF)are often associated with the development of pulmonary hypertension(PH)which leads to a higher symptom burden,worse exercise tolerance,and increased risk of death.The 6th Word Symposium on Pulmonary Hypertension held in 2018 suggested that the diagnostic criteria for PH should be modified,the diagnostic criteria has changed from mean pulmonary arterial pressure(mPAP)≥25 mmHg to>20 mmHg.This recommendation was subsequently accepted by the European Society of Cardiology/European Respiratory Society Guidelines for PH in 2022,which formally define the diagnostic criteria for PH as mPAP>20 mmHg.Studies focusing on patients with mPAP between 21 and 24 mmHg are currently lacking in China.Therefore,the latest Chinese guideline for PH(2021 version)still adopts mPAP≥25 mmHg as the diagnostic criteria for PH.Patients with mPAP between 21 and 24 mmHg were previously defined as borderline PH.Pulmonary hypertension associated with left heart failure(PH-LHF)is the most prevalent kind of PH in clinical practice.Thus,it is necessary to establish a database of patients with PH-LHF with mPAP between 2124 mmHg in China and conduct multicenter clinical studies to explore the prognosis of these patients.Objectives:This study aimed to investigate the prognosis of PH-LHF patients with mPAP between 21 and 24 mmHg.To provide an important reference for the next version of Chinese guideline on whether the diagnostic criteria for PH need to be modified.Methods:A retrospective analysis of a national multicenter prospective registry study of LHF patients who underwent RHC between January 2013 and November 2016 was performed.Patients were divided into three groups based on mPAP:(1)without PH(mPAP≤20 mmHg);(2)mPAP:21-24 mmHg;(3)mPAP≥25 mmHg.Medical histories,demographic,laboratory tests,RHC,and echocardiography were collected at baseline.Follow-up was performed every 6 months±2 weeks for at least three years.The primary outcome of this study was all-cause mortality,and the second outcome was rehospitalization for heart failure.The relationships between borderline PH and clinical outcomes were assessed by the Cox regression analysis.Results:A total of 344 LHF patients from 11 tertiary hospitals in China were enrolled,62.5%(215)patients with mPAP≥ 25 mmHg,10.8%(37)with mPAP:21-24 mmHg,and 26.7%(92)without PH(mPAP≤20 mmHg),respectively.The 3-year all-cause mortality rate was 23.1%for the mPAP≥ 25 mmHg group,16.7%for the mPAP:2124 mmHg group,and 4.5%for the without PH group,respectively.Multivariable Cox analysis revealed that patients with mPAP between 21 and 24 mmHg had a higher adjusted mortality risk(HR=3.822;95%CI:1.043-13.999;P=0.043)than without PH patients.There was no statistically significant difference in adjusted rehospitalization between 21-24 mmHg and without PH group(HR=1.599;95%CI:0.833-3.067;P=0.158).The hazard ratio for death increased progressively with increasing mPAP starting at 20 mmHg,and it was discovered that a one mmHg incremental increase in mPAP has the most significant effect on death risk between 21 and 24 mmHg.Conclusions:Borderline PH is independently related to increased 3-year mortality in LHF patients.Borderline PH-LHF has a similar prognostic significance as PH-LHF and should be treated equally.It supports the revision of the diagnostic criteria of PH to mPAP≥20 mmHg in the subsequent guidelines in China.PART Ⅲ Development and validation of a nomogram for predicting 3-year mortality in patients with pulmonary hypertension associated with left heart failureBackground:Pulmonary hypertension associated with left heart failure(PH-LHF)is a chronic progressive disease with high prevalence and mortality rates.Consequently,timely identification of patients with high mortality risk is critical.Objectives:This study aimed to build a nomogram for predicting 3-year mortality and screening high-risk PH-LHF patients.Methods:This study was a retrospective analysis of a national multicenter prospective registry study.The nomogram was developed on a training cohort of 175 patients with PH-LHF diagnosed by right heart catheterization(RHC).Multivariate Cox regression was used to identify independent predictors and develop this nomogram.The median total points obtained from the nomogram were used as a cutoff point,and patients were classified into low-and high-risk groups.The concordance index(C-index)and calibration curve were utilized to assess the predictive accuracy and discriminative ability of the nomogram.External validation was performed using a validation cohort of 77 PH-LHF patients diagnosed by RHC from other centers.Results:Multivariate Cox regression showed that the New York Heart Association functional classification(NYHA FC),uric acid level,and mean pulmonary arterial pressure(mPAP)were all independent predictors and incorporated into the nomogram.The nomogram showed good discrimination(C-index of 0.756;95%CI:0.6880.854),and good calibration.The Kaplan-Meier survival analysis showed that patients in the high-risk group had worse survival(P<0.001).In the external validation,the nomogram showed both good discrimination(C-index of 0.738;95%CI:0.5910.846)and calibration.Conclusions:The nomogram had a good performance in predicting 3-year mortality and can effectively identify high-risk patients.The nomogram will enable these highrisk patients to receive closer monitoring,and intensification of management,perhaps mitigating the longitudinal disease burden.