Department if Cardiology, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Israel.
Pulmonary Division, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Israel.
Int J Cardiol. 2019 Sep 1;290:138-143. doi: 10.1016/j.ijcard.2019.05.016. Epub 2019 May 13.
The use of the diastolic pressure gradient (DPG) for the diagnosis of combined post- and pre-capillary pulmonary hypertension (Cpc-PH) versus isolated post-capillary pulmonary hypertension (Ipc-PH) in patients with PH due to left heart disease (PH-LHD) remains controversial. We studied the incremental prognostic information provided by DPG and potential sources of disagreements between different hemodynamic criteria for Cpc-PH.
We studied 393 patients with PH-LHD who underwent right heart catheterization and were followed for hospitalizations and all-cause mortality for a median of 53 months. Patients were classified into Ipc-PH or Cpc-PH using DPG, pulmonary vascular resistance (PVR) or transpulmonary gradient (TPG)-based criteria.
Classifying PH categories according to DPG alone was not associated with a significant difference in clinical outcomes between patients with Ipc-PH and Cpc-PH (P = 0.17). By contrast, PVR criteria alone were associated with a strong prognostic separation between Ipc-PH and Cpc-PH (P = 0.005). Adding DPG to the PVR-based classification contributed no additional prognostic information. Classifying PH using the cutoff of DPG >7 mmHg or TPG >15 mmHg, resulted in an almost perfect agreement (κ statistic 0.87; 93.4% agreement). However, in cases of disagreement, occurring with low or negative DPG values, the TPG-based classification was more likely to be correct.
The DPG does not add incremental prognostic information beyond PVR. Using DPG/PVR criteria to differentiate between Ipc-PH and Cpc-PH is equivalent to using TPG/PVR criteria with a TPG threshold >15 mmHg. However, the use of DPG for diagnostic purposes may lead to misclassification of PH when DPG is low or negative.
对于左心疾病相关肺动脉高压（PH-LHD）患者，使用舒张期压力梯度（DPG）诊断复合性毛细血管前和毛细血管后肺动脉高压（Cpc-PH）与单纯性毛细血管后肺动脉高压（Ipc-PH）仍存在争议。我们研究了 DPG 提供的增量预后信息，以及不同毛细血管前 PH 诊断标准之间的分歧来源。
我们研究了 393 例接受右心导管检查的 PH-LHD 患者，中位随访 53 个月，随访内容包括住院和全因死亡率。使用 DPG、肺血管阻力（PVR）或跨肺梯度（TPG）标准，将患者分为 Ipc-PH 或 Cpc-PH。
仅根据 DPG 分类 PH 类别与 Ipc-PH 和 Cpc-PH 患者的临床结局无显著差异（P=0.17）。相比之下，仅使用 PVR 标准即可对 Ipc-PH 和 Cpc-PH 进行强烈的预后区分（P=0.005）。将 DPG 添加到基于 PVR 的分类中并未提供额外的预后信息。使用 DPG>7mmHg 或 TPG>15mmHg 的截断值进行 PH 分类，几乎可达到完美一致性（κ 统计量 0.87；93.4%的一致性）。然而，在 DPG 值较低或为负的情况下，TPG 基于分类的分类更可能是正确的。
DPG 不能提供超过 PVR 的增量预后信息。使用 DPG/PVR 标准来区分 Ipc-PH 和 Cpc-PH 与使用 TPG/PVR 标准和 TPG 阈值>15mmHg 是等效的。但是，当 DPG 较低或为负时，DPG 用于诊断目的可能会导致 PH 的错误分类。
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