Elevated Right And Left Sided Filling Pressures Determine Adverse Outcomes In Ambulatory Heart Failure With Preserved Ejection Fraction

Abstract

Introduction Heart failure with preserved ejection fraction (HFpEF) constitutes approximately half of all heart failure (HF) hospitalizations. The driving force of pathophysiology and symptoms in HFpEF are elevated filling pressures. We sought to evaluate clinical outcomes by hemodynamic parameters in ambulatory HFpEF. Methods We included patients referred to the Johns Hopkins HFpEF Clinic with a clinical diagnosis of HFpEF and right heart catheterization data. Baseline characteristics and clinical outcomes at 2 years were compared for patients with right atrial (RA) to pulmonary capillary wedge pressure (PCWP) ratio of Results Of the 161 patients included, 60 (37%) had an RA:PCWP ratio of ≥0.6 and 60 (37%) had a PCWP ≥20 mmHg. In the high RA:PCWP group, there was a significantly lower proportion of females and African Americans and lower systolic blood pressure compared to the low RA:PCWP group (Table). Patients with a high PCWP were significantly more obese, more likely to be on a beta-blocker, and had higher NT-proBNP compared to those with a low PCWP (Table). Clinical signs and symptoms of HF were not significantly different between groups, except for a higher proportion of patients with orthopnea in the low PCWP group. Event-free probability was significantly lower in the high RA:PCWP and PCWP groups compared to the low groups at 2 years (p=0.001 and 0.011 respectively, Figure). There was no significant difference in event-free probability by cardiac index ( Conclusion Elevated right and left-sided filling pressures are a key determinant of clinical outcomes in ambulatory HFpEF. Clinical signs and symptoms of HF in an obese HFpEF population may not be a reliable metric of elevated filling pressures. Therefore, invasive hemodynamic assessment for prognostication and intensification of diuretic therapy should be considered. Future therapies in HFpEF should focus on accurate detection of congestion and novel strategies for enhanced natriuresis.