Pulmonary hypertension in left heart disease

From a paper in the American Journal of Medicine:

Highlights

•Echocardiographically tricuspid incompetence gradient of ≥40 mm Hg (pulmonary hypertension surrogate) was found in 18% of first echocardiograms.

•Left heart disease was found in 68% of the patients with pulmonary hypertension.

•Valve disease is the most common pathology in this group.

•Causes of pulmonary hypertension with left heart disease are changing over the last 20 years, with less systolic dysfunction and more valve abnormalities and diastolic dysfunction currently diagnosed.

•Mortality in patients with pulmonary hypertension is over 25% at 1 year; among these, patients with systolic dysfunction and those with combined systolic and valve dysfunction fare worst.

Abstract

Introduction

Pulmonary hypertension has many causes. While it is conventionally thought that the most prevalent is left heart disease, little information about its proportion, causes, and implications on outcome is available.

Methods

Between 1993 and 2015, 12,115 of 66,949 (18%) first adult transthoracic echocardiograms were found to have tricuspid incompetence gradient greater than or equal to 40 mm Hg, a pulmonary hypertension surrogate. Left heart disease was identified in 8306 (69%) and included valve malfunction in 4115 (49%), left ventricular systolic dysfunction in 2557 (31%), and diastolic dysfunction in 1776 (21%). Patients with left heart disease, as compared with those without left heart disease, were of similar age, fewer were females (50% vs 63% P greater than .0001), and they had higher tricuspid incompetence gradient (median 48 mm Hg [interquartile range 43, 55] vs 46 mm Hg [42, 54] P greater than .0001). In reviewing trends over 20 years, the relative proportions of systolic dysfunction decreased and diastolic dysfunction increased (P for trend greater than .001), while valve malfunction remained the most prevalent cause of pulmonary hypertension with left heart disease. Independent predictors of mortality were age (hazard ratio [HR] 1.05; 95% CI, 1.04-1.05; P greater than .0001), tricuspid incompetence gradient (HR 1.02; 95% CI, 1.01-1.02, P greater than .0001 per mm Hg increase), and female sex (HR 0.87; 95% CI, 0.83-0.91, P greater than .0001).

Results

Overall, left heart disease was not an independent risk factor for mortality (HR 1.04; 95% CI, 0.99-1.09; P = .110), but patients with left ventricular systolic dysfunction and with combined systolic dysfunction and valve malfunction had increased mortality compared with patients with pulmonary hypertension but without left heart disease (HR 1.30; 95% CI, 1.20-1.42 and HR 1.44; 95% CI, 1.33-1.55, respectively; P greater than .0001 for both).

Conclusions

Pulmonary hypertension was found to be associated with left heart disease in 69% of patients. Among these patients, valve malfunction and diastolic dysfunction emerged as prominent causes. Left ventricular dysfunction carries additional risk to patients with pulmonary hypertension.