Echocardiographic risk stratification in heart failure with post-capillary pulmonary hypertension: prognostic value of LAVI and TAPSE/PASP.
LAVI and TAPSE/PASP are strong non-invasive predictors of adverse outcomes in heart failure with post-capillary pulmonary hypertension, potentially enhancing risk assessment beyond invasive methods.
Where it sits
this study against the rest of the cardiogen (aedr) corpusSummary and findings
This study evaluated the prognostic value of left atrial volume index (LAVI) and TAPSE/PASP in patients with heart failure and post-capillary pulmonary hypertension (pcPH). The primary outcome was a 3-year composite of all-cause mortality, urgent heart transplantation or LVAD, or unplanned HF hospitalization. The study found that 55% of patients met the echocardiographic risk criterion, which was associated with an increased risk of adverse events.
Abstract
<h4>Aims</h4>Post-capillary pulmonary hypertension (pcPH) is a frequent complication of heart failure (HF), associated with poor outcomes. While right heart catheterization (RHC) is the diagnostic gold standard, echocardiographic indices such as left atrial volume index (LAVI) and the TAPSE/PASP ratio may offer non-invasive prognostic value.<h4>Objectives</h4>To assess the prognostic utility of LAVI and TAPSE/PASP compared with invasive haemodynamic parameters in patients with HF and pcPH undergoing RHC.<h4>Methods and results</h4>The PH-HF study is a prospective multicentre cohort of adults with chronic HF and confirmed pcPH (mPAP > 20 mmHg and pulmonary arterial wedge pressure > 15 mmHg) enrolled across 13 French centres (2012-2018). Patients with precapillary PH or severe pulmonary/renal comorbidities were excluded. The primary outcome was a 3-year composite of all-cause mortality, urgent heart transplantation or LVAD, or unplanned HF hospitalization. Cox regression was used for survival analyses. Overall, 55% of patients met the composite echocardiographic risk criterion (LAVI > 35 mL/m² or TAPSE/PASP < 0.40), which was associated with increased risk of adverse events (HR 1.97, 95% CI 1.41-2.75; P < 0.0001). Results were consistent across HFrEF and HFpEF phenotypes. In a multivariable model including the MAGGIC score, both the echocardiographic criterion and the clinical score remained independently associated with outcomes, supporting their complementary value in risk stratification.<h4>Conclusion</h4>LAVI and TAPSE/PASP are strong, non-invasive predictors of adverse outcomes in HF with pcPH and may enhance prognostic assessment beyond invasive haemodynamics and clinical scores.
Background
This paper addresses the prognostic value of echocardiographic indices in heart failure patients with post-capillary pulmonary hypertension (pcPH). Previous studies have established that right heart catheterization (RHC) is the gold standard for diagnosis, but non-invasive methods may provide valuable prognostic information. Understanding the utility of LAVI and TAPSE/PASP could enhance risk stratification in this patient population.
Methods
The PH-HF study is a prospective multicentre cohort study involving adults with chronic heart failure and confirmed pcPH, defined as mPAP > 20 mmHg and pulmonary arterial wedge pressure > 15 mmHg. The study enrolled patients across 13 French centres from 2012 to 2018, excluding those with precapillary PH or severe pulmonary/renal comorbidities. The primary outcome was a 3-year composite of all-cause mortality, urgent heart transplantation or LVAD, or unplanned HF hospitalization, analyzed using Cox regression.
Results
The primary outcome showed that 55% of patients met the echocardiographic risk criterion (LAVI > 35 mL/m² or TAPSE/PASP < 0.40). This criterion was associated with an increased risk of adverse events, with a hazard ratio of 1.97 (95% CI 1.41-2.75) and a p-value of less than 0.0001. The findings were consistent across heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) phenotypes.
Interpretation
The results indicate that LAVI and TAPSE/PASP are significant predictors of adverse outcomes in heart failure patients with pcPH, supporting their use in clinical practice for risk stratification. However, while the statistical significance is strong, the clinical significance should be interpreted with caution, particularly given the observational nature of the study and potential confounding factors such as the exclusion of patients with severe comorbidities.
Key findings
- 55% of patients met the composite echocardiographic risk criterion (LAVI > 35 mL/m² or TAPSE/PASP < 0.40)
- HR 1.97, 95% CI 1.41-2.75; P < 0.0001 for increased risk of adverse events associated with echocardiographic criteria
- Results were consistent across HFrEF and HFpEF phenotypes
Limitations
- Observational design limits causal inference
- Exclusion of patients with severe comorbidities may affect generalizability
- Single-site study may introduce bias
- Short follow-up period of 3 years