Peak Tricuspid Regurgitation Velocity Research Articles

Combined ARNI and SGLT2i impacts on peak tricuspid regurgitant velocity and echocardiographic probability of pulmonary hypertension

Abstract Background In heart failure with reduced ejection fraction (HFrEF), the development of pulmonary hypertension (PH) is associated with poor prognosis. Recent medical advancements have substantially improved both survival rates and HF hospitalization. However, the impact of combining angiotensin receptor neprilysin inhibitor (ARNI) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) on peak tricuspid regurgitant velocity (TRV) and PH echocardiographic probability remains unexplored. Purpose We aimed to evaluate the effect of ARNI alone versus ARNI combined with SGLT2i on peak TRV and PH probability in a real-life population of outpatients with HFrEF. Methods This was an observational monocentric study including patients treated with either ARNI alone or with SGLT2i on top of ARNI. Echocardiographic examinations were performed by fully accredited operators and all parameters were analysed offline by expert operators blinded to clinical data. We performed echocardiographic evaluation in all patients before initiating treatment and at 12 months follow-up. We excluded patients who discontinued ARNI within 6 months of introduction and those who did not complete at least 6 months of follow-up with both drugs. Results 80 HFrEF patients were included, 41 receiving ARNI+SGLT2i and 39 receiving ARNI alone. Baseline mean peak TRV was similar between the two groups (280±44 cm/s and 259±48 cm/s respectively, p=0.09). At follow-up, mean peak TRV was 232±32 cm/s in ARNI+SGLT2i group and 258±45 cm/s in ARNI alone group (p=0.02). The decrease in peak TRV was significant in ARNI+SGLT2i group, p=0.0004 (Table). At baseline the echocardiographic probability of PH was comparable between both groups, p=0.53 (Figure). Nevertheless, during follow-up, the proportion of patients with high probability of PH decreased in the ARNI+SGLT2i group (from 22% to 2%), while in the ARNI alone group it did not change (Figure). Conclusions In HFrEF the combination of ARNI+SGLT2i demonstrates high effectiveness in TRV reduction, downgrading PH probability class. In our population, this evidence is primarily driven by the decrease TRV. These results may suggest the positive effect of SGLT2i on pulmonary vascular remodelling and right heart hemodynamic worth of full investigation in further studies aimed at targeting left-sided PH and its prevention strategies.

Peak atrial longitudinal strain to replace atrial volume in diastolic function grading: associations with long-term outcomes in a community-based sample with normal left ventricular ejection fraction

Abstract Background Diastolic dysfunction (DD) often precedes symptomatic heart failure and is a predictor of adverse outcomes; thus, accurate assessment and grading are crucial for early interventions. Current guidelines recommend combining multiple echocardiographic parameters, including left atrial volume index (LAVi), for diagnosing DD in patients with normal left ventricular ejection fraction (LVEF). Recently, peak atrial longitudinal strain (PALS) emerged as a more sensitive marker of left atrial function, although its added value in the grading of DD and associated adverse outcomes is scarcely explored. Purpose We aimed to investigate the impact of replacing LAVi with PALS on DD grading by its associations with long-term all-cause mortality in a low-risk, community-based sample. Methods We retrospectively identified 1319 volunteers from a population-based screening program (mean age 53.8±14.9 years, 59.1% female) with LVEF>50%. Subjects underwent echocardiography to measure mitral annular early diastolic velocities (e’), the ratio between mitral inflow early diastolic velocity (E) and e' (E/e'), tricuspid regurgitation peak velocity, LAVi, and PALS by speckle tracking. Diastolic function was initially classified according to the 2016 ASE/EACVI guidelines into normal, indeterminate, and DD groups and then reclassified by replacing LAVi>34 ml/m² with a standard PALS cut-off of <24%. The primary endpoint was all-cause mortality. Results During the median follow-up time of 11 years, 135 (10,2%) subjects met the primary endpoint. According to guideline definitions, 59 subjects were diagnosed with DD, 128 were indeterminate, and 1132 showed normal function. Kaplan-Meier analysis (Figure 1) showed significant differences in mortality between normal versus indeterminate and DD groups (log-rank p<0.001), with a three-fold (HR [95% CI]: 3.363 [1.802 - 6.274], and nearly five-fold increased risk (HR [95% CI]: 4.935 [1.919 - 12.690], respectively. Notably, no significant difference was observed between the outcomes of the indeterminate and DD groups. When subjects were reclassified using PALS instead of LAVi, 35 had DD, 75 were indeterminate, and 1209 had normal function. This classification resulted in different outcomes between groups (Figure 2, log-rank p=0.003). Compared to the normal, the indeterminate group exhibited a two-fold increase in mortality risk (HR: 2.277 [95% CI: 1.038-4.997]), while the DD group had a ten-fold increased risk (HR: 10.180 [95% CI: 2.870-36.130]). DD was associated with a nearly five-fold increase in mortality risk (HR: 4.724 [95% CI: 2.177-10.250]) compared to the indeterminate group. Conclusions In a community-based sample with normal LVEF, replacing LAVi with PALS in diastolic function classification separated groups with significant differences in their long-term all-cause mortality. This adjustment also reduced the size of the indeterminate group and refined its mortality risk.Figure 1Figure 2

Screening for stage B heart failure in Type 2 diabetes: natriuretic peptide screening alone misses echocardiographic abnormalities

Abstract Background Heart failure (HF) often manifests as the first cardiac event in individuals with type 2 diabetes mellitus (T2DM). International guidelines recommend natriuretic peptide (NP) screening for stage B/ pre-HF in asymptomatic individuals with T2DM, with echocardiography reserved for those with elevated NPs ("NP-gated" echo approach). Whether this strategy misses individuals with echocardiographic abnormalities despite normal NPs is not fully understood. Purpose To assess the proportion of individuals with T2DM who will be classified as Stage B HF based on biomarker and echocardiography, using independent and combined screening approaches. Methods We utilised the Performance of NT-proBNP In risk Stratification for Cardiovascular Events and mortality in patients with diabetes [PISCES] study (n=765, mean age 62±9 years, 62% men), which enrolled patients with T2DM with no HF. All patients underwent laboratory-based N-terminal pro-B-type NP (NT-proBNP) testing and a point-of-care artificial intelligence echocardiography (Us2.ai). Abnormal echocardiography was defined as left ventricular ejection fraction <50%, left ventricular mass index ≥115(male) or ≥95g/m2(female), left atrial volume index>34 in sinus rhythm or >40mL/m2 in atrial fibrillation, relative wall thickness (RWT) >0.42, E/e' >9, peak tricuspid regurgitation velocity >2.8m/s, pulmonary arterial systolic pressure >35mmHg. Patients with T2DM were classified into either (1) Stage B(biomarker) with elevated NT-proBNP (≥125pg/mL) and normal echocardiography, or (2) Stage B(echo) with abnormal echocardiography and normal NT-proBNP, or (3) Stage B(biomarker+echo) with elevated NT-proBNP and abnormal echocardiography or (4) no abnormalities. Results Among asymptomatic patients with T2DM, the highest proportion of individuals were in Stage B(echo) (43%), followed by those with no abnormalities (37%), Stage B(biomarker+echo) (15%) and Stage B(biomarker) (5%). Patients with Stage B(echo) (vs. no abnormalities) were older (62.5 vs 59.8 years), had a higher prevalence of hypertension (78.4 vs. 72.4%), higher systolic blood pressure (135 vs. 128 mmHg), higher RWT and higher E/e’ (p<0.001 for all). Individuals in Stage B(biomarker+echo) (versus no abnormalities) were older, had a longer duration of T2DM, higher prevalence of hypertension, atrial fibrillation, prior CVD, highest NT-proBNP levels, lowest eGFR levels, and more echocardiography abnormalities (higher RWT and E/e’). Patients identified as Stage B(biomarker) (versus no abnormalities) had a longer duration of T2DM, higher NT-proBNP levels, higher prevalence of comorbidities and comparable echocardiographic measures. Conclusion Among asymptomatic patients with T2DM, a significant proportion have subclinical cardiac abnormalities despite a lack of diagnostic NP elevation. Instead of NP-gated echocardiography, an integrated approach using both NT-proBNP and AI echocardiography may improve the early detection of Stage B HF.

High-sensitivity C-reactive protein is associated with cardiac dysfunction and morbidity in a community-based cohort

Abstract Background Inflammation is increasingly recognized as a risk factor for cardiac morbidity in the general population. Biomarkers like high-sensitivity C-reactive protein (hs-CRP) can aid in the detection of adverse systemic inflammation. The relationship between hs-CRP and cardiac structure and function is therefore a target of interest. Purpose The purpose of this study was to investigate the association of inflammation with cardiac structure and function in individuals free of overt cardiac disease. In addition, we examined if hs-CRP provided prognostic information regarding incident heart failure and myocardial infarction independent of echocardiographic measures. Methods In a community-based cohort study, participants were randomly selected for invitation from the Capital Region of Denmark. Echocardiography was performed on all the participants and measures of cardiac structure and function were obtained by blinded investigators. Participants with a history of cardiac disease were excluded from the analysis. Associations between log-transformed hs-CRP and echocardiographic measures were analyzed through uni- and multivariable linear regressions. Results A total of 3,379 individuals were included. Mean age was 55 years, 42% were female and the median hs-CRP was 1.13 (interquartile range: 0.65 - 1.47) mg/L. In the univariable analyses, increasing levels of hs-CRP were associated with worse left ventricular (LV) function including LV ejection fraction, global longitudinal strain (GLS), worse diastolic function (E/e’), worse right heart function (tricuspid regurgitation (TR) velocity and tricuspid annular plane systolic excursion (TAPSE)) and higher left ventricular (LV) mass index (p < 0.001 for all measures) (figure). When adjusting for sex, age, physical activity, smoking status, body mass index, blood pressure, hypercholesterolemia, diabetes, hypertension, creatinine, and heart rate, only LVEF (p < 0.001), GLS, (p < 0.001), E/e’ (p = 0.027), TAPSE (p = 0.008) and peak TR velocity (p = 0.015) remained significantly associated with increasing hs-CRP levels. In multivariable Cox regression adjusting for clinical characteristics and echocardiographic measures including LV ejection fraction, LV mass index, E/e’, TAPSE and GLS, higher hs-CRP was significantly associated with both heart failure and myocardial infarction (table) (HR for heart failure: 1.30, 95% CI: 1.03–1.66 p = 0.030; HR for acute myocardial infarction: 1.40, 95% CI: 1.04 – 1.89, p = 0.028, per doubling of hs-CRP). We did not find any interactions between hs-CRP and outcome among different types of echocardiographic phenotypes. Conclusion In the general population, higher levels of hs-CRP were associated with declining systolic, diastolic and right heart function. The associations persisted when adjusting for clinical characteristics. In addition, hs-CRP was associated with cardiac events independent of cardiac function as assessed by echocardiography.Linear regression splinesCox regressions

Echocardiographic profiles of patients with CPCPH and IPCPH in HFpEF: insights from the PHHF study

Abstract Background The 2022 ESC/ERS guidelines changed the definition of post-capillary pulmonary hypertension (pcPH) in heart failure (HF) by lowering the level of mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR). Yet, the echocardiographic profile of HF with preserved ejection fraction (PEF) patients according to their mPAP and RVP is not known. Objectives To investigate the echocardiographic profile of HFPEF patients according to their mPAP and RVP. Methods Stable HF patients with the need for right heart catheterization were enrolled from 2010 to 2018 and prospectively followed-up in this multicenter study. All patients had a right heart catheterization and an echocardiography within the 24 hours. PcPH was characterized by a pulmonary wedge pressure exceeding 20 mm Hg and mean mPAP greater than 20 mm Hg, from an isolated state when PVR was less than 2 Wood units (WU, IpcPH) to a combined form when PVR exceeded 2 WU (CpcPH). Results Out of 662 HF patients included in PHHF study, 268 (40%) were classified as having HFpEF (35% male, median age 71 yo). Compared to IpcPH patients, CpcPH patients had higher tricuspid regurgitation peak velocity (sPAP, 3.53 vs 3.00 m/s, p<0.01), lower S tricuspid tissue Doppler velocity (10 vs. 11 cm/s, p 0.01) and TAPSE (18 vs. 21 mm, p< 0.01) and lower TAPSE/sPAP ratio (0.3 vs. 0.4, p<0.01). There were no differences between groups regarding both right ventricle and right atrial diameter and area. Conclusion In HFpEF patients with PH, CpcPH patients had worse right ventricular function despite similar remodeling when compared to IpcPH patients

Echocaridographic assessment of pulmonary hypertension: improving the probability

Abstract Introduction Pulmonary hypertension (PH) is a cardio-pulmonary disorder characterised by raised pulmonary artery pressure (mPAP >20mmHg) leading to right ventricular failure, and death if left untreated. Transthoracic echocardiography (TTE) assessment of PH uses a probability-based approach, combining peak tricuspid regurgitant velocity with other supporting signs. We evaluated the latest ESC TTE PH guidelines in a real-world UK dataset and identified markers that may improve the sensitivity of the existing algorithm. Method Retrospective analysis of 447 patients referred for initial PH assessment. This was a select population of patients who underwent both TTE and right heart catheter (RHC) (mean time to RHC = 40±30 days). In addition to current TTE PH probability markers we analysed right ventricular free wall strain (RVFWS). Measurements were made by a single operator using Tomtec Arena 2020. Crosstabulation, ROC curve analysis and T-tests were used to compare variables between PH and no PH. Results Mean sample age was 64±15 yrs (61% female). 6.9% (n=4) of the no PH group had pulmonary mid-systolic notching, which may be due to pseudo-notching attributable to incomplete Doppler envelope. Sensitivity and specificity of current ESC TTE probability guidelines were 83%, and 65% respectively (95% C.I.). However, within the low probability group (i.e. those felt to be less likely to have PH) 62% (n=63) had confirmed PH at RHC (mPAP = 28±9). The addition of RVFWS as an additional marker to the existing supporting signs of PH (Table 1) resulted in an improvement of the sensitivity of the algorithm to 92% with a mild reduction in specificity (63%). The number of false negatives were reduced by 51%. Of these, the majority were in the low TTE probability group (n = 32). Conclusions Using current PH TTE probability algorithms classifies a significant proportion of those with PH as having a low TTE PH probability. The addition of RVFWS improves the sensitivity of the existing algorithm to 92% and reduces false negatives by 51%.

Efficacy and limitation of nonparoxysmal atrial fibrillation ablation in patients with heart failure with preserved ejection fraction.

Catheter ablation for atrial fibrillation (AF) reduces heart failure (HF) hospitalization in patients with HF with preserved ejection fraction (HFpEF). However, the long-term outcomes and subclinical HF after nonparoxysmal AF ablation in HFpEF patients have not been fully evaluated. One-hundred-ninety nonparoxysmal AF patients with left ventricular ejection fraction ≥50% who underwent first-time AF ablation were studied. HFpEF was diagnosed from a history of congestive HF and/or combined criteria of N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration and transthoracic echocardiogram parameters, including average septal-lateral E/e' and tricuspid regurgitation peak velocity. Ninety-five patients with HFpEF (HFpEF group) were compared with 95 patients without HF (CNT group). Low voltage area (LVA) was defined as an area with a bipolar electrogram of <0.5 mV covering >5% of the total left atrial surface. The primary endpoint was a composite of death from any cause or hospitalization for worsening HF. The secondary endpoint was subclinical HFpEF defined from NT-proBNP concentration and average septal-lateral E/e' or tricuspid regurgitation peak velocity at 6-12 months after the procedure irrespective of the rhythm. Kaplan-Meier curves showed that the primary composite endpoint did not differ between the two groups (mean follow-up period 707 ± 75 days, log-rank p = 0.5330). However, significantly more patients in the HFpEF group reached the secondary endpoint (42 [44%] vs. 13 [14%], p < 0.0001). Multivariate analysis revealed that a high preablation NT-proBNP (odds ratio [OR] 1.001, 95% confidence interval [CI] 1.001-1.002, p = 0.0040) and the existence of LVA (OR 5.983, 95% CI 1.463-31.768, p = 0.0194) independently predicted the secondary endpoint in HFpEF patients. After nonparoxysmal AF ablation, mortality of HFpEF patients was not inferior compared to patients without coexisting HF. However, subclinical HF occasionally persisted especially in HFpEF patients with a high preprocedure NT-proBNP concentration and LVA.

Liver stiffness as a prognostic parameter and tool for risk stratification in advanced cardiac transthyretin amyloidosis.

In light of increasing therapeutic options, risk stratification of advanced cardiac transthyretin amyloidosis (ATTR-CA) is gaining clinical importance to avoid ineffective treatments. Liver stiffness as a marker of hypervolemia and hepatic congestion might predict mortality in advanced ATTR-CA and allow to identify patients at highest risk. Proven ATTR-CA patients underwent repeated vibration-controlled transient elastography (VTCE) and standardized serial workup within the local amyloidosis cohort study AmyKoS. Spearman correlation analyses and Cox regressions were performed to evaluate the prognostic value. 41 patients with ATTR-CA were included with median age of 76.6 (55.1-89.1) years, of which 90.2% were male and > 92% wild-type ATTR-CA. In total, 85 VCTE examinations were performed. Median follow-up was 43.7 (2.4-75.6) months; 26.8% of the patients died. At the first clinical evaluation, median left ventricular (LV) absolute global longitudinal strain (GLS) was 11.4 (5.2-19.0) % and median liver stiffness was 6.3 (2.4-22.9) kPa, both significantly correlated with mortality. NT-proBNP possessed statistically significant predictive power in ATTR-CA with more preserved LV function (absolute GLS ≥ 10), whereas stiffness seemed to be more discriminative for ATTR-CA with absolute GLS < 10. The use of alternative congestion surrogates such as liver vein dilation and tricuspid regurgitation peak velocity (tr-vmax) showed congruent results. Liver stiffness shows prognostic value regarding all-cause mortality and allows risk stratification in advanced ATTR-CA, particularly in those with markedly impaired longitudinal LV function. These results are transferable to other congestion surrogates.

Impact of Tricuspid Regurgitation Severity on Accuracy of Echocardiographic Estimation of Systolic Pulmonary Artery Pressure in Patients With Pulmonary Arterial Hypertension

Objective: This study aims to investigate the impact of tricuspid regurgitation (TR) severity on the accuracy of echocardiographic estimation of systolic pulmonary arterial pressure (sPAP) in patients with pulmonary arterial hypertension (PAH). Methods: Patients who were diagnosed with PAH and had a right heart catheterization (RHC) and echocardiography examination were selected retrospectively from May 2018 to December 2021. sPAP measured by RHC is used as the gold standard. A difference in sPAP of less than 10 mmHg between echocardiographic estimation by peak TR velocity and RHC measurement was defined as accurate, with a difference ≥10 mmHg considered inaccurate. The factors affecting the accuracy of echocardiographic sPAP estimation were analyzed by univariate and multivariate analysis. Results: A total of 138 patients aged (45.57 ± 15.97) years with PAH were enrolled. sPAP measured by echocardiography and RHC were (80.83 ± 23.46) and (81.62 ± 30.05) mmHg, respectively. The values of the 2 methods were highly correlated (r = 0.809, P &lt; 0.01) and Bland-Altman plots showed good consistency. The accuracy rate of sPAP estimation by echocardiography was 42.03% (58/138). In the 57.97% (80/138) of patients where echocardiography was inaccurate, sPAP was overestimated in 28.26% (39/138) and underestimated in 29.71% (41/138). Univariate analysis showed that there was a statistically significant difference between the accurate and inaccurate groups in World Health Organization-Function Class, N-terminal pro-B-type natriuretic peptide, severity of TR, tricuspid annular plane systolic excursion (TAPSE), sPAP-RHC, mean pulmonary artery pressure, pulmonary vascular resistance (P &lt; 0.05). Multivariate logistic regression analyses identified the TR severity (odds ratio = 2.292, 95% confidence interval: 1.126–4.667, P = 0.022) and TAPSE (odds ratio = 0.733, 95% confidence interval: 0.621–0.865, P &lt; 0.001) as independent predictors for the accuracy of echocardiographic sPAP estimation. Conclusion: Higher TR severity and lower TAPSE values reduce the accuracy of sPAP estimated by echocardiography. Therefore, TR severity and right heart function should be considered when echocardiography is used to estimate sPAP by the TR velocity.

Incremental prognostic utility of congestion markers in cardiac transthyretin amyloidosis.

Congestion is prognostically relevant in cardiac transthyretin amyloidosis (ATTR-CA), but whether congestion has an incremental prognostic value beyond the well-established, congestion-sensitive NT-proBNP is unknown. Therefore, we aimed to comparatively evaluate the prognostic utility of several congestion surrogates over NT-proBNP. We estimated hazard ratios by Cox proportional hazards regressions with time-varying covariates from a panel data set of the local amyloidosiscohort study AmyKoS. Different models were compared by using chi(χ)2-statistics measuring overall model significance. 131 ATTR-CA patients (wild-type 84.0%, hereditary 6.9%, without genetic testing 9.2%; median age 78.7 (quartiles 73.3, 82.1) years; 85.5% male) with 566 observations across a median follow-up of 38.2 (30.6; 48.2) months were analyzed. 83.2% received disease-modifying treatment; 20.6% participated concurrently in placebo-controlled gene silencer trials. Information on congestion improved biomarker-driven risk stratification and identified patients at the highest risk. Echocardiographic congestion markers performed better than clinical findings and daily diuretic use/dosage. Relevant adjusters were daily diuretic dosage, disease-modifying treatment, eGFR, and right atrial volume. NT-proBNP and the tricuspid regurgitation peak velocity (tr-vmax) provided an easy-to-use stratification with overall model performance similar to NAC and Mayo staging systems. Further analyses are necessary for validation and to identify the optimal cut points of the congestion markers.

Relevance of the TAS'/PASP Ratio as a Predictor of Outcomes in Patients with Heart Failure with a Reduced Ejection Fraction.

There is evidence that right ventricular (RV) contractile function, especially its coupling with the pulmonary circulation, has an important prognostic value in patients with left ventricular dysfunction. This study aimed to identify the best echocardiographic parameters of RV function and pulmonary artery systolic pressure (PASP) alone or in the form of the index of right ventricular-pulmonary artery coupling (RV-PA coupling) to determine the best predictor of 1-year major adverse cardiovascular events (MACE), which were defined as cardiovascular death and cardiac decompensation in heart failure patients with reduced ejection fraction (HFrEF). The study enrolled 191 HFrEF patients (mean age 62.28 ± 12.79 years, 74% males, mean left ventricular ejection fraction (LVEF) 25.53 ± 6.87%). All patients underwent clinical, laboratory, and transthoracic echocardiographic (TTE) evaluation, focusing on assessing RV function and non-invasive parameters of RV-PA coupling. RV function was evaluated using fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and peak tricuspid annular systolic velocity (TAS'). PASP was estimated by peak tricuspid regurgitation velocity (TRVmax) and corrected by assumed right atrial pressure relative to the dimension and collapsibility of the inferior vena cava. The TAPSE/PASP and TAS'/PASP ratios were taken as an index of RV-PA coupling. During the follow-up (mean period of 340 ± 84 days), 58.1% of patients met the composite endpoint. The independent predictors of one-year outcome were shown to be advanced age, atrial fibrillation, indexed left atrial systolic volume (LAVI), LVEF, TAPSE/PASP, and TAS'/PASP. TAS'/PASP emerged as the strongest independent predictor of prognosis, with a hazard ratio (HR) of 0.67 (0.531-0.840), p < 0.001. Reconstructing the ROC curve 0.8 (0.723-0.859), p < 0.001, we obtained a threshold value of TAS'/PASP ≤ 0.19 (cm/s/mm Hg) (sensitivity 74.0, specificity 75.2). Patients with TAS'/RVSP ≤ 0.19 have a worse prognosis (Log Rank p < 0.001). This study confirmed previously known independent predictors of adverse outcomes in patients with HfrEF-advanced age, atrial fibrillation, LAVI, and LVEF-but non-invasive parameters of RV-PA coupling TAPSE/PASP and TAS'/PASP improved risk stratification in patients with HFrEF. Variable TAS'/PASP has been shown to be the most powerful, independent predictor of one-year outcome.

Endothelial Function Correlates With Pulmonary Pressures in Subjects With Clinically Suspected Pulmonary Hypertension

BackgroundImpaired pulmonary circulation hemodynamics are characteristic of pulmonary hypertension. We therefore sought to evaluate possible correlations between endothelial function non-invasively assessed by flow-mediated dilation (FMD) and hemodynamic parameters at right heart catheterization (RHC) in patients with clinically suspected pulmonary hypertension. MethodsConsecutive outpatients with suspected PH were enrolled in the study. In all patients, endothelial function was assessed by FMD and hemodynamic parameters (pulmonary artery pressure (PAP), pulmonary vascular resistances (PVR)) were derived by RHC. ResultsNinety-five consecutive patients with suspected pulmonary hypertension were enrolled in the study (mean age 63±13 years, 58% male) and included in the analysis. FMD values were significantly correlated with systolic (s)PAP levels (r=-0.29, P=0.016); correlation with pulmonary vascular resistance values was of borderline significance (r=-0.21, p=0.78).After multivariable regression analysis including age, gender, TAPSE and peak tricuspid regurgitation velocity (peak-TVR), and FMD, the latter remained significantly correlated with sPAP values (B=-47, p=0.02). After classifying patients according to median levels of peak TRV and FMD into 3 groups (neither, either, or both impaired), progressively increased levels of sPAP, mPAP and PVR were found (P for trend <0.001 in all cases). ConclusionsFMD values were inversely related with sPAP levels in a small population of patients with clinically suspected PH. In combination with peak TRV levels, FMD values non-invasively assessed were predictive of increased sPAP, mPAP, and PVR.

Evaluation of left ventricular filling pressure by echocardiography in patients with atrial fibrillation

BackgroundEchocardiography is widely used to evaluate left ventricular (LV) diastolic function in patients suspected of heart failure. For patients in sinus rhythm, a combination of several echocardiographic parameters can differentiate between normal and elevated LV filling pressure with good accuracy. However, there is no established echocardiographic approach for the evaluation of LV filling pressure in patients with atrial fibrillation. The objective of the present study was to determine if a combination of several echocardiographic and clinical parameters may be used to evaluate LV filling pressure in patients with atrial fibrillation.ResultsIn a multicentre study of 148 atrial fibrillation patients, several echocardiographic parameters were tested against invasively measured LV filling pressure as the reference method. No single parameter had sufficiently strong association with LV filling pressure to be recommended for clinical use. Based on univariate regression analysis in the present study, and evidence from existing literature, we developed a two-step algorithm for differentiation between normal and elevated LV filling pressure, defining values ≥ 15 mmHg as elevated. The parameters in the first step included the ratio between mitral early flow velocity and septal mitral annular velocity (septal E/e’), mitral E velocity, deceleration time of E, and peak tricuspid regurgitation velocity. Patients who could not be classified in the first step were tested in a second step by applying supplementary parameters, which included left atrial reservoir strain, pulmonary venous systolic/diastolic velocity ratio, and body mass index. This two-step algorithm classified patients as having either normal or elevated LV filling pressure with 75% accuracy and with 85% feasibility. Accuracy in EF ≥ 50% and EF < 50% was similar (75% and 76%).ConclusionsIn patients with atrial fibrillation, no single echocardiographic parameter was sufficiently reliable to be used clinically to identify elevated LV filling pressure. An algorithm that combined several echocardiographic parameters and body mass index, however, was able to classify patients as having normal or elevated LV filling pressure with moderate accuracy and high feasibility.

Peculiarities of the evolution of pulmonary hypertension in patients with ischemic heart failure 12 months after myocardial revascularization

Pulmonary hypertension (PH) associated with left heart disease is common and has an important impact on disease progression, morbidity and mortality. We aimed to identify the particularities of PH evolution in patients with ischemic heart failure during 12 months after myocardial revascularization (MRev) by coronary artery bypass grafting or percutaneous coronary angioplasty.Methods: The research included 281 patients undergoing MRev (mean age=63.2±9.7 years, 76.5%- men). Follow up period - 12.6±1.6 months. The patients were divided according to the echocardiographic probability of PH (PHPr) into 3 groups: low PHPr (117 patients), intermediate PHPr (74 patients), high PHPr (90 patients). Results. The prevalence of PH 12 months after MRev constituted 69.7%, increasing by 10% compared to the initial period. We highlighted a negative evolution of PHPr during 1 year after MRev: 42.8% of patients with initially low PHPr and 54.1% of those with intermediate PHPr had a higher degree of PHPr. The peak tricuspid regurgitation velocity and the pulmonary artery systolic pressure did not change significantly during 12 months after the acute event. The negative evolution of PHPr was determined by the negative dynamics of additional echocardiographic signs suggestive for PH: the right atrium area (+2,2±0.4mm), the right ventricular outflow tract acceleration time (-7.6±1.2ms), the inferior vena cava diameter (+0.55±0.2mm). During 12 months after MRev, 5 patients died, all of them had high PHPr (p&lt;0.01), and the hospitalization rate was significantly higher in this group (high PHPr - 57.1%, intermediate PHPr - 43.2%, low PHPr - 38.7%, p&lt;0.05). Conclusions: The PH prevalence 12 months after MRev was 69.7%, increasing by 10% compared to the initial period. A negative evolution of PHPr was noted during 1 year follow up. Patients with high and intermediate PHPr had a higher rate of hospitalizations during the 12 months after MRev and all deceased patients had high PHPr.

Cardiopulmonary phenotype in systemic sclerosis associated pulmonary hypertension

IntroductionPulmonary hypertension (PH) associated with systemic sclerosis (SSc) increases morbidity and mortality. Cardiopulmonary comorbidities, as per the 2021 PH consensus, play a role in the choice of therapy between monotherapy and combination therapy. MethodsA cross-sectional study was conducted in patients with SSc based on the 2013 ACR/EULAR criteria or very early disease (VEDOSS 2011). PH was considered if they met the following criteria: pulmonary artery systolic pressure (PASP)>39mmHg or peak tricuspid regurgitation velocity (PTRV)>3.4m/s, PASP between 33 and 39mmHg or PTRV between 2.9 and 3.4m/s plus two additional findings suggestive of PH. PH was classified as type 2 if LVEF<50% or moderate to severe diastolic dysfunction was present; type 3 if extensive interstitial disease on tomography>20% or forced vital capacity (FVC)<75%; type 4 if abnormalities related to embolism were detected on scintigraphy or tomography. If patients did not meet these criteria, they were classified as type 1 PH. Complete data on cardiopulmonary risk factors and other factors were required. The frequency of these factors in the population and differences between groups based on risk factors were estimated. ResultsA total of 228 patients were selected. Three had type 2 PH, 24 had type 3, and 40 had type 1 PH, with the majority (75%) having at least one cardiopulmonary risk factor, and 47.5% having more than one. Mild diastolic dysfunction (25%) and hypertension (35%) were the most prevalent. In the type 1 PH group, those with risk factors experienced an increase in the number of years with Raynaud's phenomenon, anticentromere antibodies, and gastrointestinal symptoms (p<0.05). ConclusionIn patients with PH, 75% have one, and 45% have two or more risk factors.

Association of Pulmonary Artery Pressures With Mortality in Adults With Reduced Left Ventricular Ejection Fraction

BackgroundThe independent effect of pulmonary hypertension (PHT) severity on mortality in those with reduced left ventricular ejection fraction (LVEF) is not well known. ObjectivesThe authors aimed to examine the prognostic impact of increasingly elevated pulmonary pressures in a large clinical cohort of adults with reduced LVEF. MethodsThe authors analyzed data from the National Echocardiography Database of Australia, a large clinical registry linking routine echocardiographic investigations to mortality. In 23,675 adults with a recorded tricuspid regurgitation peak velocity (TRV) and reduced LVEF (<50%), the authors evaluated the relationship between conventional thresholds of increasing risk of PHT and mortality during median follow-up of 2.9 years (Q1-Q3: 1.0-5.4 years). ResultsMean age was 70 ± 15 years, and 7,498 (31.7%) individuals were female. Overall, 8,801 (37.2%) had normal (TRV <2.5 m/s), 7,061 (29.8%) had borderline (2.5-2.8 m/s), 5,676 (24.0%) intermediate (2.9-3.4 m/s), and 2,137 (9.0%) individuals had high-risk PHT (>3.4 m/s). With increasing risk of PHT, 1- and 5-year actuarial mortality increased from 13.3% and 43.8% to 41.5% and 81.4%, respectively (P < 0.0001) from normal to severely elevated TRV. The adjusted HR of mortality increased by 1.31-fold (95% CI: 1.23-1.38), 1.82-fold (95% CI: 1.72-1.93), and 2.38-fold (95% CI: 2.21-2.56) in those with borderline, intermediate, and high risk of PHT respectively, compared with normal TRV. Further analyses suggested a distinctive threshold with a TRV reached >2.41 m/s (adjusted HR: 1.18 [95% CI: 1.04-1.33]). ConclusionsThe authors demonstrate the prevalence and negative prognostic impact of increasingly elevated TRV levels in individuals with reduced LVEF, with a threshold for mortality lying within the range of “borderline risk” PHT.

Cardiopulmonary exercise test to detect cardiac dysfunction from pulmonary vascular disease

BackgroundCardiac dysfunction from pulmonary vascular disease causes characteristic findings on cardiopulmonary exercise testing (CPET). We tested the accuracy of CPET for detecting inadequate stroke volume (SV) augmentation during exercise, a pivotal manifestation of cardiac limitation in patients with pulmonary vascular disease.MethodsWe reviewed patients with suspected pulmonary vascular disease in whom CPET and right heart catheterization (RHC) measurements were taken at rest and at anaerobic threshold (AT). We correlated CPET-determined O2·pulseAT/O2·pulserest with RHC-determined SVAT/SVrest. We evaluated the sensitivity and specificity of O2·pulseAT/O2·pulserest to detect SVAT/SVrest below the lower limit of normal (LLN). For comparison, we performed similar analyses comparing echocardiographically-measured peak tricuspid regurgitant velocity (TRVpeak) with SVAT/SVrest.ResultsFrom July 2018 through February 2023, 83 simultaneous RHC and CPET were performed. Thirty-six studies measured O2·pulse and SV at rest and at AT. O2·pulseAT/O2·pulserest correlated highly with SVAT/SVrest (r = 0.72, 95% CI 0.52, 0.85; p < 0.0001), whereas TRVpeak did not (r = -0.09, 95% CI -0.47, 0.33; p = 0.69). The AUROC to detect SVAT/SVrest below the LLN was significantly higher for O2·pulseAT/O2·pulserest (0.92, SE 0.04; p = 0.0002) than for TRVpeak (0.69, SE 0.10; p = 0.12). O2·pulseAT/O2·pulserest of less than 2.6 was 92.6% sensitive (95% CI 76.6%, 98.7%) and 66.7% specific (95% CI 35.2%, 87.9%) for deficient SVAT/SVrest.ConclusionsCPET detected deficient SV augmentation more accurately than echocardiography. CPET-determined O2·pulseAT/O2·pulserest may have a prominent role for noninvasive screening of patients at risk for pulmonary vascular disease, such as patients with persistent dyspnea after pulmonary embolism.

Cardiopulmonary phenotype in systemic sclerosis associated pulmonary hypertension

IntroductionPulmonary hypertension (PH) associated with systemic sclerosis (SSc) increases morbidity and mortality. Cardiopulmonary comorbidities, as per the 2021 PH consensus, play a role in the choice of therapy between monotherapy and combination therapy. MethodsA cross-sectional study was conducted in patients with SSc based on the 2013 ACR/EULAR criteria or very early disease (VEDOSS 2011). PH was considered if they met the following criteria: pulmonary artery systolic pressure (PASP)>39mmHg or peak tricuspid regurgitation velocity (PTRV)>3.4m/s, PASP between 33 and 39mmHg or PTRV between 2.9 and 3.4m/s plus two additional findings suggestive of PH. PH was classified as type 2 if LVEF<50% or moderate to severe diastolic dysfunction was present; type 3 if extensive interstitial disease on tomography>20% or forced vital capacity (FVC)<75%; type 4 if abnormalities related to embolism were detected on scintigraphy or tomography. If patients did not meet these criteria, they were classified as type 1 PH. Complete data on cardiopulmonary risk factors and other factors were required. The frequency of these factors in the population and differences between groups based on risk factors were estimated. ResultsA total of 228 patients were selected. Three had type 2 PH, 24 had type 3, and 40 had type 1 PH, with the majority (75%) having at least one cardiopulmonary risk factor, and 47.5% having more than one. Mild diastolic dysfunction (25%) and hypertension (35%) were the most prevalent. In the type 1 PH group, those with risk factors experienced an increase in the number of years with Raynaud's phenomenon, anticentromere antibodies, and gastrointestinal symptoms (p<0.05). ConclusionIn patients with PH, 75% have one, and 45% have two or more risk factors.

Right Ventricle Strain Assessed by 2-Dimensional Speckle Tracking Echocardiography (2D-STE) to Evaluate Pulmonary Hypertension in Dogs with Dirofilaria immitis.

Echocardiographic assessment of the right ventricle is helpful for analysing the pathophysiology of heartworm disease and detecting pulmonary hypertension (PH) in dogs. In veterinary cardiology, the study of myocardial deformation using two-dimensional speckle tracking (2D-STE) echocardiography has become increasingly acknowledged as useful for quantifying right ventricular function. The aim of this study was to evaluate the usefulness of myocardial deformation strain of the right ventricular free wall (FWS), global deformation strain of the right ventricle, including the interventricular septum (GS), and tissue motion annular displacement of the tricuspid valve (TMAD) in a cohort of dogs with heartworm (Dirofilaria immitis) disease and to determine cut-off values for detecting the presence of PH. Out of the 93 dogs tested, 71% were diagnosed with heartworm infection. PH was identified in 41% of the infected dogs following the American College of Veterinary Internal Medicine (ACVIM) guidelines, based on the peak tricuspid regurgitation velocity to calculate the tricuspid regurgitation pressure gradient (TRPG), while other routine measurements were used, including the right pulmonary artery distensibility index (RPADi). The 2D-STE mode measurements were determined using Right Ventricular Automated Function Imaging (RV AFI®) software. The statistical analysis showed significant differences in the studied parameters among dogs with and without PH. Additionally, sensitivity (sen) and specificity (sp) cut-off values were obtained (GS ≥ -21.25%, sen 96%, sp 86.4%; FWS ≥ -21.95%, sen 92.56%, sp 95.5%; TMAD ≤ 0.85 cm, sen 70.4%, sp 83.3%). These results demonstrated that GS, FWS, and TMAD could be used as supplementary and alternative variables to conventional echocardiographic measurements when detecting PH in dogs with heartworm disease.

Role of CT attenuation correction gated SPECT MPI in prediction of pulmonary hypertension

ObjectiveTo elucidate the value of gated SPECT-MPI using CT attenuation correction (AC) for prediction of pulmonary hypertension (PHT) in coronary patients by estimation of reliability of non-contrast CT in measurement of main pulmonary artery diameter (MPAd) as well as by assessment of potential predictive role of gated parameters as beneficial accessory findings. BackgroundContrast-enhanced CT is known as an accurate tool for assessment of MPAd to predict PHT. [1] The low-dose non-contrast CT which is used for AC in MPI study, however, has an unclear value in precise vascular diameter measurement; it is also uncertain whether gated parameters could help to predict PHT. Methods and patientsA total of 207 patients, who had a transthoracic echocardiography and MPI with an interval of maximum one month, underwent this retrospective study. PHT was defined as a RVSP ≥36 mmHg by echocardiography; peak tricuspid regurgitation velocity (PTRV) was also calculated to use as a criterion for PHT. Of all subjects, 120 had RVSP ≥ 36 and 87 showed RVSP < 36; there also were 191 and 16 patients with PTRV ≤ 3.4 m/s and >3.4 m/s, respectively. Comparison was made unconnectedly between each group regarding the echocardiography results with the MPI parameters, with and without CT-AC, including MPAd derived from CT as well as RV/LV uptake ratio, shape index and septal wall motion and thickening scores to define the best indicators of PHT. ResultsThere was a significant association between established benchmark of PHT in echocardiography (RVSP), with MPAd derived from non-contrast CT as well as with LV shape index from gated study and RV/LV uptake ratio acquired from non-AC SPECT-MPI. Also, stress and rest RV/LV uptake ratio, MPAd, LV end-systolic and LV end-diastolic shape indexes are significantly higher in patients with RVSP ≥ 36 mmHg compare to patients with RVSP < 36 mmHg. ConclusionsGated-SPECT-MPI using CT-AC can predict PHT by reliable estimation of MPAd as well as by defining RV/LV uptake ratio and shape index, providing an added clinical value for this invaluable modality in cardiac patients.