The Diastolic Pulmonary Gradient Does Not Predict Survival in Patients With Pulmonary Hypertension Due to Left Heart Disease

Abstract

Objectives To evaluate if diastolic pulmonary gradient (DPG) can predict survival in patients with pulmonary hypertension due to left heart disease (PH-LHD). Background Patients with combined post- and pre-capillary PH-LHD have worse prognosis than those with passive pulmonary hypertension. The transpulmonary gradient (TPG) and pulmonary vascular resistance (PVR) have commonly been used to identify high-risk patients. However, these parameters have significant shortcomings and do not always correlate with pulmonary vasculature remodeling. Recently, it has been suggested that DPG may be better marker, yet its prognostic ability in patients with cardiomyopathy has not been fully assessed. Methods A retrospective cohort of 1236 patients evaluated for unexplained cardiomyopathy at Johns Hopkins Hospital was studied. All patients underwent right heart catheterization and were followed until death, cardiac transplantation or the end of the study period (mean time 4.4 years). The relationships between DPG, TPG or PVR and survival in subjects with PH-LHD (n=469) were evaluated with Cox Proportional Hazards Regression and Kaplan Meier analyses. Results DPG was not significantly associated with mortality (HR 1.02; p=0.10) in PH-LHD whereas elevated TPG and PVR predicted death (HR 1.02, p=0.046 and HR 1.11, p=0.002, respectively). Similarly, DPG did not differentiate survivors from non-survivors at any selected cutpoints including a DPG of 7mmHg. Conclusions In this retrospective study of patients with cardiomyopathy and PH-LHD, an elevated DPG was not associated with worse survival.

Pulmonary Hypertension in Patients with Heart Failure and Preserved Ejection Fraction: Differential Diagnosis and Management

“…We have chosen a PVR of 3 WU because this usually denotes the presence of PVD in patients with PAH. Although Tampakakis et al 46 did not show additional benefit in determining prognosis when combining PVR and DPG, we believe that DPG still has strong physiological grounding and that its role should not be dismissed. This does leave us with a group of patients who have DPG ≥ 7 mmHg and PVR < 3 WU or DPG < 7 mmHg and PVR ≥ 3 WU, whose phenotype is presently unclear.…”

Acute hemodynamic effects of inhaled sodium nitrite in pulmonary hypertension associated with heart failure with preserved ejection fraction

“…The exact definition of PH in the setting of left heart disease is still debated, but includes at least the criteria of a mean pulmonary artery pressure greater than or equal to 25 mmHg and a pulmonary capillary wedge pressure greater than or equal to 15 mmHg (10). Additional hemodynamic criteria of PH in the setting of left heart disease, along with how such criteria affect prevalence and outcomes, continue to be debated, with the ultimate goal to identify a phenotype amenable to specific targeted therapies (1,2,(10)(11)(12)(13)(14)(15).…”

Prognostic Factors for Survival in Pulmonary Hypertension Due to Left Heart Disease

“…1,2 Recent epidemiological studies in group 2 PH focused on markers of pulmonary vascular remodeling, such as transpulmonary pressure gradient (TPG), 3-6 pulmonary vascular resistance (PVR), 3,4, 6 and diastolic pulmonary vascular pressure gradient (DPG). 5- 8 The results obtained so far, however, are controversial. Furthermore, sustained PH leads to right ventricular dysfunction, which is partly represented as elevated mean right atrial pressure (RAP).…”

“…6 In contrast, Tedford et al reported the poor prognostic ability of DPG in patients with PH due to LHD even though they used multiple cut-off points. 7, 8 Their subjects included younger patients 7, 8 and those with less coronary artery disease 8 compared with the Gerges et al study. 6 The problem is that DPG is sensitive to measurement error because the absolute value is small, and DPG is affected by many factors including lung disease, sepsis, hypoxia, acidosis, and coronary artery bypass surgery.…”