Patients with heart failure with preserved ejection fraction (HFpEF) who have mild pulmonary hypertension (PH) are at increased risk for adverse clinical outcomes, according to a review published in the American Journal of Respiratory and Critical Care Medicine.1
PH is a prevalent HFpEF subphenotype that is due to pulmonary venous and pre-capillary remodeling from left atrial hypertension.3-5 Previous studies conducted in the United States have demonstrated a wide continuum of clinical risk relative to mean pulmonary artery pressure (mPAP), including hospitalization and mortality, which changed the mPAP threshold for defining PH in the setting of left heart disease from >25 mmHg to >20 mmHg.2,6-8,9-11
Researchers sought to determine whether mPAP 20 to 24 mmHg is an independent predictor of clinical events in HFpEF and whether the association of mPAP >20 mmHg is generalizable to international HFpEF populations.1
A study of patients hospitalized for heart failure (HF) in Japan demonstrated an increased risk for future HF hospitalizations with an mPAP ≥20 mmHg, and even in patients with an mPAP ≥15 mmHg.12
A significant increase in the risk for adverse clinical outcome was maintained in several multivariate analyses.1 This study included a relatively small sample size of 183 patients, and therefore larger international studies are needed.
The review authors concluded that, “Viewing mild PH in a new light — as a high-risk clinical parameter in HFpEF — could pave a way forward for early intervention (eg, diet modification, prescription exercise enhanced diabetes control) irrespective of symptom burden.”1 They added that, “In principle, such a shift may ultimately give rise to opportunities for HFpEF (or PH) prevention.”
- Simon MA, Maron BA. Pulmonary hypertension in heart failure with preserved ejection fraction patients: where to draw the line [published online April 30, 2019]. Am J Respir Crit Care Med. doi: 10.1164/rccm.201903-0689ED
- Vanderpool RR, Saul M, Nouraie M, Gladwin MT, Simon MA. Association between hemodynamic markers of pulmonary hypertension and outcomes in heart failure with preserved ejection fraction. JAMA Cardiol. 2018;3:298-306.
- Maron BA, Galie N. Diagnosis, treatment, and clinical management of pulmonary arterial hypertension in the contemporary era: a review. JAMA Cardiol. 2016;1:1056-1065.
- Guazzi M, Gomberg-Maitland M, Arena R. Pulmonary hypertension in heart failure with preserved ejection fraction. J Heart Lung Transplant. 2015;34:273-281.
- Rosenkranz S, Gibbs JS, Wachter R, De Marco T, Vonk-Noordegraaf A, Vachiery JL. Left ventricular heart failure and pulmonary hypertension. Eur Heart J. 2016;37:942-954.
- Maron BA, Hess E, Maddox TM, et al. Association of borderline pulmonary hypertension with mortality and hospitalization in a large patient cohort: insights from the Veterans Affairs clinical assessment, reporting, and tracking program. Circulation. 2016;133:1240-1248.
- Assad TR, Maron BA, Robbins IM, et al. Prognostic effect and longitudinal hemodynamic assessment of borderline pulmonary hypertension. JAMA Cardiol. 2017;2:1361-1368.
- Maron BA, Brittain EL, Choudhary G, Gladwin MT. Redefining pulmonary hypertension. Lancet Respir Med. 2018;6:168-170.
- Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2019;53:1801913.
- Kovacs G, Avian A, Tscherner M, et al. Characterization of patients with borderline pulmonary arterial pressure. Chest. 2014;146:1486-1493.
- Maron BA, Wertheim BM, Gladwin MT. Under pressure to clarify pulmonary hypertension clinical risk. Am J Respir Crit Care Med. 2018;197:423-426.
- Nishihara T, Yamamoto E, Tokitsu T, et al. New definition of pulmonary hypertension in heart failure with preserved ejection fraction patients [printed online March 27, 2019]. Am J Respir Crit Care Med. doi: 10.1164/rccm.201901-0148LE