Division of Cardiology (E.T., B.W.K., E.K.K., D.A.K., R.J.T.) and Division of Pulmonary and Critical Care Medicine (T.M.K., R.D., S.C.M., P.M.H.), Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., H.H.P.). Division of Cardiology, Mayo Clinic, Rochester, MN (B.A.B., W.L.M.). Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle (P.J.L.). Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston (B.A.H., R.J.T.).
Circ Heart Fail. 2018 Apr;11(4):e004436. doi: 10.1161/CIRCHEARTFAILURE.117.004436.
Patients with combined post- and precapillary pulmonary hypertension due to left heart disease have a worse prognosis compared with isolated postcapillary. However, it remains unclear whether increased mortality in combined post- and precapillary pulmonary hypertension is simply a result of higher total right ventricular load. Pulmonary effective arterial elastance (Ea) is a measure of total right ventricular afterload, reflecting both resistive and pulsatile components. We aimed to test whether pulmonary Ea discriminates survivors from nonsurvivors in patients with pulmonary hypertension due to left heart disease and if it does so better than other hemodynamic parameters associated with combined post- and precapillary pulmonary hypertension.
We combined 3 large heart failure patient cohorts (n=1036) from academic hospitals, including patients with pulmonary hypertension due to heart failure with preserved ejection fraction (n=232), reduced ejection fraction (n=335), and a mixed population (n=469). In unadjusted and 2 adjusted models, pulmonary Ea more robustly predicted mortality than pulmonary vascular resistance and the transpulmonary gradient. Along with pulmonary arterial compliance, pulmonary Ea remained predictive of survival in patients with normal pulmonary vascular resistance. The diastolic pulmonary gradient did not predict mortality. In addition, in a subset of patients with echocardiographic data, Ea and pulmonary arterial compliance were better discriminators of right ventricular dysfunction than the other parameters.
Pulmonary Ea and pulmonary arterial compliance more consistently predicted mortality than pulmonary vascular resistance or transpulmonary gradient across a spectrum of left heart disease with pulmonary hypertension, including patients with heart failure with preserved ejection fraction, heart failure with reduced ejection fraction, and pulmonary hypertension with a normal pulmonary vascular resistance.
与单纯的毛细血管后肺动脉高压相比，由左心疾病引起的毛细血管后和毛细血管前肺动脉高压的患者预后更差。然而，增加的死亡率在毛细血管后和毛细血管前肺动脉高压患者中是否仅仅是由于总右心室负荷增加，目前仍不清楚。肺有效动脉弹性(Ea)是右心室总后负荷的一种衡量标准，反映了阻力和脉动成分。我们旨在检验肺 Ea 是否能区分左心疾病引起的肺动脉高压患者的存活者和非存活者，以及它是否比其他与毛细血管后和毛细血管前肺动脉高压相关的血流动力学参数更好。
我们结合了来自学术医院的 3 个大型心力衰竭患者队列（n=1036），包括心力衰竭射血分数保留型（n=232）、射血分数降低型（n=335）和混合人群（n=469）。在未调整和 2 个调整模型中，肺 Ea 比肺血管阻力和肺跨压更能准确预测死亡率。与肺动脉顺应性一起，肺 Ea 在肺血管阻力正常的患者中仍然可以预测生存率。舒张性肺梯度不能预测死亡率。此外，在一组有超声心动图数据的患者中，Ea 和肺动脉顺应性比其他参数更能区分右心室功能障碍。
在一系列伴有肺动脉高压的左心疾病中，包括射血分数保留型心力衰竭、射血分数降低型心力衰竭和肺动脉阻力正常的肺动脉高压患者，肺 Ea 和肺动脉顺应性比肺血管阻力或肺跨压更能一致地预测死亡率。
