Pulmonary hypertension in patients with heart failure with reduced ejection fraction: impact of the new definition of pulmonary hypertension
Authors: Vysocansky S , Luknar M , Lesny P 
Published: November 2023

Abstract

Background
Prevalence, haemodynamic character, and associated factors of pulmonary hypertension (PH) in heart failure with reduced left ventricular ejection fraction (HFrEF) according to the 2022 European Society of Cardiology (ESC) PH definition remain unclear.

Purpose
To describe the prevalence of PH and its phenotypes in patients with advanced HFrEF according to the 2022 PH definition and analyse characteristics of the respective PH groups.

Methods
We retrospectively analysed 175 consecutive patients (pts) (136 men) with advanced HFrEF referred to a single centre. All pts underwent right heart catheterization (RHC). We identified pts with post-capillary PH which was defined as mean pulmonary artery pressure (mPAP) &gt; 20 mm Hg and pulmonary artery wedge pressure (PAWP) &gt; 15 mm Hg. Pts with mPAP ≤ 20 mm Hg and/or PAWP ≤ 15 mm Hg were labelled as pts without post-capillary PH. According to pulmonary vascular resistance (PVR), PH was further classified as isolated post-capillary (IPC PH) (PVR ≤ 2 Wood units) or combined post- and pre-capillary PH (CPC PH) (PVR ≤ 2 Wood units). We compared selected demographic, clinical, echocardiographic, laboratory, and haemodynamic parameters between the individual groups.

Results
Median age of the pts was 54 (18-69) years and mean left ventricular ejection fraction (LVEF) 21.9 ± 6.7 %. Out of 175 pts included, 146 (83 %) pts had post-capillary PH. Twenty-nine (17%) pts did not meet the post-capillary PH criteria. Thirty-five (20%) pts had IPC PH and 111 (63%) pts CPC PH. In comparison with the pts without post-capillary PH, pts with post-capillary PH had longer history of HFrEF (6.8 ± 5.6 vs 3.8 ± 4.6 years, p&lt;0.01), lower systolic blood pressure (108 ± 13 vs 120 ± 20 mmHg, p&lt;0.01), lower LVEF (21 ± 6 vs 26 % ± 8 p&lt;0.001), larger left atrial diameter (51 ± 7 vs 45 ± 7 mm, p&lt;0.001), right ventricular diameter (39 ± 9 vs 34 ± 8 mm, p&lt;0.01), higher prevalence of renal insufficiency (29 vs 59%, p&lt;0.05) and atrial fibrillation (12 vs 0 %, p&lt;0.05), and higher natriuretic peptide levels (4565 ± 4087 vs 1976 ± 2376 pg/mL, p&lt;0.001). Patients with CPC PH were older (54 ± 10 vs 47 ± 13 years, p &lt; 0.001), had lower 6-minute walking distance (390 ± 126 vs 439 ± 74 years, p&lt;0.05), higher prevalence of renal insufficiency (33 vs 14 %, p&lt;0.05), and diabetes mellitus (32 vs 11 % p&lt;0.05) than pts with IPC PH. Alteration in pulmonary haemodynamics was more pronounced in CPC PH than IPC PH, with higher mPAP (40 ± 9 vs 29 ± 5 mm Hg, p&lt;0.001), PAWP (27 ± 6 vs 22 ± 5 mm Hg, p&lt;0.001), and lower cardiac index (1.9 ± 0.4 vs 2.3 ± 0.5 L/min/m2, p&lt;0.001).

Conclusion
Post-capillary PH according to 2022 definition is frequent in pts with advanced HFrEF, with CPC PH prevalence three times as high as in ICP PH. Despite lowering both the threshold for presence of PH and pre-capillary component in the recent definition, PH and CPC PH still seem to reflect a more advanced stage of HFrEF.