Doppler estimates of pulmonary vascular resistance to phenotype pulmonary hypertension in heart failure

Ashwin Venkateshvaran,Aristomenis Manouras,Barbro Kjellström,Lars H Lund,Jasmin Hamade

doi:10.1007/s10554-019-01591-z

Abstract

An accurate distinction between isolated post-capillary pulmonary hypertension (Ipc-PH) and combined post- and pre-capillary pulmonary hypertension (Cpc-PH) is integral to therapy and prognosis in heart failure (HF). This study aimed to compare the ability of four previously validated Doppler estimates of pulmonary vascular resistance (PVRDoppler) to distinguish Ipc-PH from Cpc-PH in a well-defined HF population. Consecutive subjects referred for HF assessment underwent standard echocardiography immediately followed by right heart catheterization (RHC). Subjects with atrial fibrillation, acute coronary syndrome, significant valvular disease or poor image quality were excluded. PVRDoppler estimates were correlated with invasive PVR and agreement was studied using Bland–Altman analysis. Receiver operating characteristics analyses were performed to determine the ability of PVRDoppler methods to identify PVR > 3WU. 55 HF subjects (58 ± 16 years, 55% Ipc-PH) were analyzed. PVRDoppler estimates demonstrated weak to modest associations with invasive PVR. The Doppler method proposed by Abbas et al. demonstrated relatively strong discriminatory ability to distinguish Ipc-PH from Cpc-PH (AUC = 0.79; 95% CI 0.63–0.96; p = 0.001). However, Bland–Altman analysis revealed wide limits of agreement (bias = 0; SD = 1.83WU) and greater variability at higher mean PVR. Conclusions: PVRDoppler estimates demonstrate reasonable ability to distinguish Ipc-PH from Cpc-PH but may not be reliable independent PH distinguishers in HF.

Highlights

Subjects with heart failure (HF) commonly present with post-capillary pulmonary hypertension (PH), which is associated with poor prognosis [1, 2]
We aimed to explore the utility of Doppler methods to distinguish PH phenotypes in HF by
All consecutive subjects referred to the Karolinska University Hospital for right heart catheterization (RHC) from February 2014 through February 2018 for the assessment of HF were screened for enrollment

Summary

Introduction

Subjects with heart failure (HF) commonly present with post-capillary pulmonary hypertension (PH), which is associated with poor prognosis [1, 2]. Based on severity of pulmonary vascular resistance (PVR), current guidelines classify the PH into: a) isolated post-capillary PH (Ipc-PH), characterized by pulmonary venous congestion with passive rise in pulmonary pressures and b) combined post- and precapillary PH (Cpc-PH) marked by additional superimposed. PVR measurement by right heart catheterization (PVRRHC) is the preferred method to distinguish PH phenotypes in HF. In subjects with advanced HF, non-invasive assessment of PVR may be useful in serial assessment of hemodynamic suitability for heart transplantation and for tailoring pharmacological therapy. Multiple methods to assess PVR by Doppler (PVRDoppler) have been proposed but are not widely utilized owing to inconclusive and conflicting results [5,6,7,8,9,10]. No studies have compared the discriminatory strength of PVRDoppler methods to distinguish Ipc-PH from Cpc-PH in a well-defined HF population

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