Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.
Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy.
J Card Fail. 2023 Sep;29(9):1261-1272. doi: 10.1016/j.cardfail.2023.04.009. Epub 2023 May 5.
Right heart failure (RHF) is associated with a dismal prognosis in patients with pulmonary hypertension (PH). Exercise right heart catheterization may unmask right heart maladaptation as a sign of RHF. We sought to (1) define the normal limits of right atrial pressure (RAP) increase during exercise; (2) describe the right heart adaptation to exercise in PH owing to heart failure with preserved ejection fraction (PH-HFpEF) and in pulmonary arterial hypertension (PAH); and (3) identify the factors associated with right heart maladaptation during exercise.
We analyzed rest and exercise right heart catheterization from patients with PH-HFpEF and PAH. Right heart adaptation was described by absolute or cardiac output (CO)-normalized changes of RAP during exercise. Individuals with noncardiac dyspnea (NCD) served to define abnormal RAP responses (>97.5th percentile). Thirty patients with PH-HFpEF, 30 patients with PAH, and 21 patients with NCD were included. PH-HFpEF were older than PAH, with more cardiovascular comorbidities, and a higher prevalence of severe tricuspid regurgitation (P < .05). The upper limit of normal for peak RAP and RAP/CO slope in NCD were >12 mm Hg and ≥1.30 mm Hg/L/min, respectively. PH-HFpEF had higher peak RAP and RAP/CO slope than PAH (20 mm Hg [16-24 mm Hg] vs 12 mm Hg [9-19 mm Hg] and 3.47 mm Hg/L/min [2.02-6.19 mm Hg/L/min] vs 1.90 mm Hg/L/min [1.01-4.29 mm Hg/L/min], P < .05). A higher proportion of PH-HFpEF had RAP/CO slope and peak RAP above normal (P < .001). Estimated stressed blood volume at peak exercise was higher in PH-HFpEF than PAH (P < .05). In the whole PH cohort, the RAP/CO slope was associated with age, the rate of increase in estimated stressed blood volume during exercise, severe tricuspid regurgitation, and right atrial dilation.
Patients with PH-HFpEF display a steeper increase of RAP during exercise than those with PAH. Preload-mediated mechanisms may play a role in the development of exercise-induced RHF.
右心衰竭（RHF）与肺动脉高压（PH）患者的预后不良有关。运动右心导管检查可揭示右心适应不良，作为 RHF 的征象。我们试图：（1）定义运动时右心房压（RAP）升高的正常范围；（2）描述 PH 中因射血分数保留的心力衰竭（PH-HFpEF）和肺动脉高压（PAH）引起的右心适应；（3）确定运动时右心适应不良的相关因素。
我们分析了 PH-HFpEF 和 PAH 患者的静息和运动右心导管检查结果。通过运动时 RAP 的绝对值或心输出量（CO）归一化变化来描述右心的适应。以非心源性呼吸困难（NCD）患者来定义异常的 RAP 反应（>97.5 百分位数）。纳入了 30 例 PH-HFpEF、30 例 PAH 和 21 例 NCD 患者。PH-HFpEF 患者比 PAH 患者年龄更大，心血管合并症更多，且严重三尖瓣反流的发生率更高（P<0.05）。NCD 患者的最大 RAP 和 RAP/CO 斜率的正常上限分别为>12mmHg 和≥1.30mmHg/L/min。PH-HFpEF 的最大 RAP 和 RAP/CO 斜率高于 PAH（20mmHg[16-24mmHg]比 12mmHg[9-19mmHg]和 3.47mmHg/L/min[2.02-6.19mmHg/L/min]比 1.90mmHg/L/min[1.01-4.29mmHg/L/min]，P<0.05）。更大比例的 PH-HFpEF 患者的 RAP/CO 斜率和最大 RAP 高于正常值（P<0.001）。PH-HFpEF 患者在运动峰值时的估计应激血容量高于 PAH（P<0.05）。在整个 PH 队列中，RAP/CO 斜率与年龄、运动时估计应激血容量的增加率、严重三尖瓣反流和右心房扩张相关。
PH-HFpEF 患者在运动时 RAP 的升高幅度比 PAH 患者更大。前负荷介导的机制可能在运动诱导的 RHF 发展中起作用。
