Low Pulmonary Artery Pulsatility Index May Identify High Risk for Cardiovascular Disease

Hospitalization for MI or stroke increases patients' functional impairment.
Hospitalization for MI or stroke increases patients’ functional impairment.
Researchers examined the relationship between pulmonary artery pulsatility index and multiple adverse outcomes in patients at risk for cardiovascular disease.

Patients with low pulmonary artery pulsatility index (PAPi) have a greater risk of all-cause mortality, major adverse cardiac events, and heart failure (HF) hospitalizations, with the highest risk in the lowest quartile. These finding were published in Circulation: Heart Failure.

Researchers evaluated consecutive ambulatory and hospitalized patients receiving right heart catheterization (RHC) from 2005 to 2016 and obtained clinical characteristics from participants’ medical records.

The primary outcomes were all-cause mortality and HF hospitalization, and the secondary outcome was major adverse cardiac events (MACE). All-cause mortality was based on National Social Security Death Master Index and hospital records and abstracted on June 10, 2020.

A total of 8285 individuals (mean aged, 63±13 years; 39% women) were included. The median physiologic PAPi values within each quartile were as follows: Q1, 1.7 (1.3-2); Q2, 2.8 (2.5-3); Q3, 4.2 (3.8-4.8); and Q4, 8.7 (6.8-14). After a mean follow-up of 6.7±3.3 years, 3006 deaths, 2668 MACEs, and 2004 HF hospitalizations occurred.

The Kaplan-Meier curves for probability of MACE and HF hospitalizations by PAPi showed that the greatest risk for adverse outcomes was in patients in the lowest PAPi quartile (adjusted log-rank P <.001 for Q1 vs Q4), with an intermediate risk of outcomes in quartiles 2 and 3 vs the highest quartile (Q2 vs Q4, adjusted log-rank P =.03 for MACE and P =.01 for HF hospitalizations; Q3 vs Q4, adjusted log-rank P =.02 for MACE and P =.002 for HF hospitalizations).

Having a lower PAPi was associated with all-cause mortality (hazard ratio [HR], 0.90 per 1 SD higher in log-transformed PAPi [95% CI, 0.85-0.96], P <.001), MACE (HR, 0.81 [95% CI, 0.77-0.85], P <.001), and HF hospitalization (HR, 0.73 [95% CI, 0.69-0.78], P <.001).

The risk of death was increased in patients in the lower PAPi quartile groups, including a 15% higher risk of death in Q3, 20% in Q2, and 60% in Q1, with the highest PAPi quartile being the reference group.

Similar associations of PAPi quartiles were found with MACE and HF hospitalizations. Patients in the lowest vs the highest PAPi quartile had an increased risk for future MACE (multivariable-adjusted HR, 1.80 [95% CI, 1.56-2.07], P <.001) and HF hospitalization (HR, 2.08 [95% CI, 1.76-2.47], P <.001).

The investigators noted that they could not control for referral bias and confounding by indication for RHC. Also, analysis relied on code-based diagnoses of MACE and HF endpoints, and follow-up was limited to patients who had longitudinal care in the authors’ health care system.

“Our findings suggest that a low PAPi can be utilized to serve as a risk factor for adverse events across a spectrum of disease,” the researchers noted. “Future studies are needed to determine whether change in PAPi modifies risk of mortality or cardiovascular hospitalizations in specific disease populations and if identification of this at-risk population may allow for targeted intervention to change disease trajectory.”

Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Zern EK, Wang D, Rambarat P, et al. Association of pulmonary artery pulsatility index with adverse cardiovascular events across a hospital-based sample. Circ Heart Fail. Published online February 9, 2022. doi: 10.1161/CIRCHEARTFAILURE.121.009085