Pulmonary hypertension due to chronic heart failure of ischemic genesis: clinical phenotypes determined by the right ventricular-pulmonary artery coupling

Aim. To study the clinical phenotypes of the right ventricular-pulmonary artery coupling (RV-PA coupling) and prognostic features in patients with pulmonary hypertension associated with ischemic chronic heart failure (PH-iCHF).

Material and methods. A total of 69 stable patients with PH-iCHF and different left ventricular ejection fractions (LVEF) were examined. PH was defined as an increase in systolic pulmonary artery pressure (sPAP) above 30 mm Hg according to transthoracic echocardiography. The probability of PH was compared to the number of confirmed PH cases. The prevalence of PH-iCHF among CHF patients was established. Correlation between RV-PA coupling and LVEF was assessed. Clinical phenotypes were based on RV-PA coupling values as the tricuspid annular plane systolic excursion (TAPSE) and sPAP ratio. Adverse outcomes such as all-cause mortality and hospitalizations due to CHF decompensation over a follow-up period of 13.2±0.9 months were analyzed.

Results. PH-iCHF occurred in 3.3% of CHF cases. sPAP above 30 mm Hg corresponded to 34.8% of patients with high probability of PH. For every 10% increase in LVEF, there was a corresponding increase in RV-PA coupling by 0.096 mm/mmHg. Based on the severity of RV-PA dissociation, three clinical phenotypes were formed: severe (<0.28 mm/mmHg), moderate (≥0.28 and ≤0.47 mm/mmHg) and mild (>0.47 mm/mmHg). Severe RV-PA dissociation was more frequently characterized by significant clinical manifestations (lower limb edema in 53%, ascites in 21% of cases), poor functional state (PH functional class III in 79% of cases), low exercise tolerance (six-minute walk test distance 267.2±107.4 m) and prolonged hospital stays (9.9±4.9 bed-days). High probability of PH was present in 67% of cases with severe RV-PA dissociation. There was no difference in time-to-adverse-outcome across clinical phenotypes. Predictors of adverse prognosis included RV-PA coupling ≤0.47 and ≤0.28 mm/mmHg, sPAP ≥40 mmHg, TAPSE ≤18 mm, right atrial area ≥18 cm², and transverse diameter of right ventricle ≥3.5 cm.

Conclusion. The RV-PA coupling provides additional characteristics of clinical and functional status and identifies early adverse outcomes in patients with PH-iCHF.

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