Risk assessment in pulmonary hypertension associated with heart failure and preserved ejection fraction

Agarwal, Richa; Shah, Sanjiv J.; Foreman, Aimee J.; Glassner, Cherylanne; Bartolome, Sonja D.; Safdar, Zeenat; Coslet, Sandra L.; Anderson, Allen S.; Gomberg-Maitland, Mardi

doi:10.1016/j.healun.2011.11.017

« Previous Next »The Journal of Heart and Lung Transplantation
Volume 31, Issue 5 , Pages 467-477, May 2012

Risk assessment in pulmonary hypertension associated with heart failure and preserved ejection fraction

Richa Agarwal, MD
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
Sanjiv J. Shah, MD
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Aimee J. Foreman, MA
- ICON Clinical Research, San Francisco, California
Cherylanne Glassner, BS
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
Sonja D. Bartolome, MD
- Section of Pulmonary and Critical Care, Department of Medicine, University of Texas Southwestern, Dallas, Texas
Zeenat Safdar, MD
- Section of Pulmonary and Critical Care, Baylor College of Medicine, Houston, Texas
Sandra L. Coslet, RN, MBA
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
Allen S. Anderson, MD
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
Mardi Gomberg-Maitland, MD, MS
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
- Reprint requests: Mardi Gomberg-Maitland, MD, MS, Associate Professor of Medicine, Director of Pulmonary Hypertension, University of Chicago Hospitals, 5841 S Maryland Ave, MC 5403, Rm L08, Chicago, IL 60637. Telephone: 773-702-5589. Fax: 773-702-0218

published online 06 January 2012.

Background

Pulmonary hypertension (PH) is common in patients with left heart failure (HF), especially those with HF and preserved ejection fraction (HFpEF). However, there is limited data on risk stratification in these patients.

Methods

Baseline clinical and hemodynamic variables of 339 patients with World Health Organization (WHO) Group 2 PH, 90% of whom had HFpEF, were studied to derive a multivariate Cox proportional hazards model. A simplified prognostic risk score was created based on the outcome of all-cause mortality. Nine predictors, significant after stepwise multivariable regression (p < 0.05), were used to create the risk score. Components of the risk score were functional class, diastolic blood pressure, pulmonary artery saturation, interstitial lung disease, hypotension on initial presentation, right ventricular hypertrophy, diffusion capacity of the lung for carbon monoxide, and 2 serum creatinine variables (≤ 0.9 mg/dl and ≥ 1.4 mg/dl).

Results

Overall 2-year survival was 73.8% ± 2.4% in the derivation cohort, and 87.5% ± 2.3%, 66.4% ± 4.9%, and 24.4% ± 6.7% for risk scores of 0 to 2, 3 to 4, and 5+, respectively (p < 0.0001 for the trend), with a C-index of 0.76 (95% confidence interval [CI], 0.71–0.81). The risk score was validated in 2 independent PH-HFpEF cohorts: 179 patients with a C-index of 0.68 (95% CI, 0.55–0.80) and 117 patients with a C-index of 0.68 (95% CI, 0.53–0.83). For the 3 cohorts combined (N = 635), the overall C-index was 0.72 (95% CI 0.68–0.76). In all 3 cohorts individually and in the 3 cohorts combined, the risk score predicted death (hazard ratio, 1.4–1.6; p < 0.01).

Conclusions

Several clinical factors independently predict death in PH-HFpEF confirmed by validation. A novel risk score composed of these factors can be used to determine prognosis and may be useful in making therapeutic decisions.

Keywords: heart failure , pulmonary hypertension , epidemiology , prognosis