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J Am Coll Cardiol, 2009; 53:1119-1126, doi:10.1016/j.jacc.2008.11.051
© 2009 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HEART FAILURE

Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction

A Community-Based Study

Carolyn S.P. Lam, MBBS*,{dagger}, Véronique L. Roger, MD, MPH*, Richard J. Rodeheffer, MD*, Barry A. Borlaug, MD*, Felicity T. Enders, PhD{ddagger} and Margaret M. Redfield, MD*,*

* Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
{dagger} Yong Loo Lin School of Medicine, Singapore, Singapore
{ddagger} Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota

Manuscript received August 20, 2008; revised manuscript received November 17, 2008, accepted November 30, 2008.

* Reprint requests and correspondence: Dr. Margaret M. Redfield, 200 First Street SW, Rochester, Minnesota 55905 (Email: redfield.margaret{at}mayo.edu).

Objectives: This study sought to define the prevalence, severity, and significance of pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF) in the general community.

Background: Although HFpEF is known to cause PH, its development is highly variable. Community-based data are lacking, and the relative contribution of pulmonary venous versus pulmonary arterial hypertension (HTN) to PH in HFpEF is unknown. We hypothesized that PH would be a marker of symptomatic pulmonary congestion, distinguishing HFpEF from pre-clinical hypertensive heart disease.

Methods: This community-based study of 244 HFpEF patients (age 76 ± 13 years; 45% male) was followed up using Doppler echocardiography over 3 years. Control subjects were 719 adults with HTN without HF (age 66 ± 10 years; 44% male). Pulmonary artery systolic pressure (PASP) was derived from the tricuspid regurgitation velocity and PH defined as PASP >35 mm Hg. Pulmonary capillary wedge pressure (PCWP) was estimated from the ratio of early transmitral flow velocity to early mitral annular diastolic velocity.

Results: In HFpEF, PH was present in 83% and the median (25th, 75th percentile) PASP was 48 (37, 56) mm Hg. PASP increased with PCWP (r = 0.21; p < 0.007). Adjusting for PCWP, PASP was higher in HFpEF than HTN (p < 0.001). The PASP distinguished HFpEF from HTN with an area under the receiver-operating characteristic curve of 0.91 (p < 0.001) and strongly predicted mortality in HFpEF (hazard ratio: 1.3 per 10 mm Hg; p < 0.001).

Conclusions: PH is highly prevalent and often severe in HFpEF. Although pulmonary venous HTN contributes to PH, it does not fully account for the severity of PH in HFpEF, suggesting that a component of pulmonary arterial HTN also contributes. The potent effect of PASP on mortality lends support for therapies aimed at pulmonary arterial HTN in HFpEF.

Key Words: pulmonary hypertension • diastolic heart failure • heart failure with preserved ejection fraction

Abbreviations and Acronyms
  AUC = area under the curve
  COPD = chronic obstructive pulmonary disease
  EF = ejection fraction
  HF = heart failure
  HFpEF = heart failure with preserved ejection fraction
  HTN = hypertension
  PASP = pulmonary artery systolic pressure
  PCWP = pulmonary capillary wedge pressure
  PH = pulmonary hypertension
  TR = tricuspid regurgitation


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