Combined Pre- And Post-capillary PH Research Articles

Combined post- and pre-capillary pulmonary hypertension in heart failure with preserved ejection fraction.

Over 2.5 million patients in the USA suffer from heart failure with preserved ejection fraction (HFpEF), and pulmonary hypertension (PH) is present in the majority of these patients. PH represents an adverse prognostic factor in HFpEF and has been identified as a potential therapeutic target to improve symptoms and outcomes. The recognition and investigation of a subset of patients with superimposed pulmonary vascular disease (on top of pulmonary venous hypertension) has led to further subclassification of PH due to left heart disease (PH-LHD) into two categories: isolated post-capillary PH and combined post- and pre-capillary PH (CpcPH). In this review, we (1) describe the evolution of the diagnostic criteria of PH-LHD; (2) identify the diagnostic modalities that can be utilized for the identification of patients with CpcPH-HFpEF; (3) review the literature on the prevalence, clinical characteristics, and prognostic factors of CpcPH-HFpEF; (4) discuss recent and ongoing clinical trials investigating the effectiveness of selective pulmonary vasodilators in PH-LHD; and (5) propose future areas for further investigation of the etiology and pathophysiological mechanisms contributing to the development of CpcPH and highlight important considerations in the design of future trials to promote better characterization of this clinical entity. CpcPH-HFpEF is a distinct subset within HFpEF and one that may respond to targeted therapeutics.

Abstract 14302: One-Year Survival in Heart Failure Patients With Preserved Ejection Fraction and Isolated Post-Capillary or Combined Post- and Pre-Capillary Pulmonary Hypertension

Introduction: Patients with combined post- and pre-capillary pulmonary hypertension (CpcPH) or isolated post-capillary pulmonary hypertension (PH) have been understudied due to limited hemodynamic information from right heart catheterization (RHC), which is not routinely performed in heart failure patients. This study compared the characteristics and outcomes of stable heart failure patients with no PH, isolated PH, and CpcPH determined by diastolic pulmonary gradient. Hypothesis: We hypothesized CpcPH would have lower 1-year survival compared to no PH or isolated PH patients undergoing RHC. Methods: We used the Dartmouth Dynamic Registry to identify patients with heart failure and preserved ejection fraction that underwent RHC at Dartmouth Hitchcock Medical Center between 1994 and 2012. CpcPH was defined by a diastolic pulmonary gradient >7mmHg. We obtained mortality data from the National Death Index. We compared demographic, clinical, laboratory, and hemodynamic characteristics of patients with no PH, isolated PH, and CpcPH. We used Kaplan-Meier statistics and multivariable Cox proportional hazards models to compare hazard for 1-year mortality for patients with no PH, isolated PH, and CpcPH adjusted for age, sex, diabetes, chronic kidney disease, and atrial fibrillation. Results: We identified 724 patients, of which 29% had no PH, 63% had isolated PH, and 7% had CpcPH. Mean follow up time was 341.8 days with a total of 676.1 person-years. There was a significant difference in crude one-year mortality; 4.0 for no PH, 8.4 for isolated PH and 21.0 (per 100 person-years) for CpcPH (log rank p =0.001). Adjusted Cox proportional hazard ratios compared to patients with no PH were 1.6 (95%CI: 0.1, 3.4) for isolated PH and 5.3 (95%CI: 2.1, 13.9) for CpcPH. Conclusions: Patients with CpcPH had worse survival than patients with isolated or no PH. Diastolic pulmonary gradient should be measured as a risk marker for identifying patients at high-risk of 1-year mortality.

ECHOCARDIOGRAPHIC PREDICTORS OF COMBINED PRE AND POST CAPILLARY PULMONARY HYPERTENSION (PH) IN A POPULATION OF SYSTOLIC HEART FAILURE WITH WHO GROUP II PULMONARY HYPERTENSION

Diastolic pressure difference of 7 mm Hg has been shown to be very good discriminator of the presence of pre-capillary component in patients with WHO group II PH. Presence of combined pre and post capillary pulmonary hypertension (CPC-PH) portends highest risk of mortality in patients with WHO group

(89) - The Diastolic Pulmonary Gradient as a Predictor of Adverse Outcomes in Patients With Acute Decompensated Heart Failure

There is currently no consensus definition for pulmonary hypertension (PH) in patients with left heart disease (LHD). The diastolic pulmonary gradient (DPG; PADp-PAWP) is not influenced by stroke volume and has been proposed as a criterion for defining isolated post-capillary (Ipc-PH) vs combined post- and pre-capillary PH (Cpc-PH). The aim of this study was to define the prevalence of combined PH and determine whether a hemodynamic classification system based on the DPG predicts adverse outcomes in patients with acute heart failure.