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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 45-48

Clinical outcomes study of echocardiography imaging to define relationship between significant pulmonary hypertension and right ventricular dysfunction: Indian scenario


1 Department of Cardiology, Division of Cardiovascular Imaging, Kiran Multisuper Specialty Hospital and Research Center, Surat, Gujarat, India
2 Department of Cardiac Imaging, Care Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication9-Mar-2018

Correspondence Address:
Dr. Keyur Vora
Department of Cardiology, Division of Cardiovascular Imaging, Kiran Multi super specialty Hospital and Research Center, Surat, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_71_17

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  Abstract 

Objective: Pulmonary hypertension (PH) is one of the fundamental echocardiography parameters of prognostic importance in heart failure (HF) diseases. Recently, right ventricular (RV) function is being increasingly recognized as critical parameter in terms of mortality outcomes both in acute and chronic HF. We sought to determine the prognostic significance of PH and RV function in patients of acute and chronic HF from retrospective institutional data. Methodology: We studied 306 patients with HF presentation including acute decompensated HF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH as PASP >50 mmHg and tricuspid annular plane systolic excursion (TAPSE) <1.6 cm along with global RV fractional area change. The primary endpoint was all-cause mortality during 3-year follow-up. Results: PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV dysfunction had PH (58.1%). Patients with normal RV function and PH had an intermediate risk. However, patients with RV dysfunction without PH were not at increased risk for 3-year mortality. Conclusion: Critical echocardiography parameters in the evaluation of HF include PASP for pressure and volume overload status as well as RV function. The incremental prognosis is also determined by PH and RV function. The compounding effect of PH & RV dysfunction is detrimental in terms of high morbidity rates and mortality outcomes.

Keywords: Echocardiography, heart failure, noninvasive imaging, pulmonary hypertension, right ventricle, ventricular dysfunction


How to cite this article:
Vora K, Christopher J. Clinical outcomes study of echocardiography imaging to define relationship between significant pulmonary hypertension and right ventricular dysfunction: Indian scenario. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:45-8

How to cite this URL:
Vora K, Christopher J. Clinical outcomes study of echocardiography imaging to define relationship between significant pulmonary hypertension and right ventricular dysfunction: Indian scenario. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2018 Sep 18];2:45-8. Available from: http://www.jiaecho.org/text.asp?2018/2/1/45/227038


  Introduction Top


PH is a syndrome and not a disease and represents a final stage in the evolution of progressive diseases of different etiology which, at last, generated elevated pressure in pulmonary circulation. Pulmonary hypertension (PH) is a common complication of chronic heart failure (HF).[1] Furthermore, increased pulmonary pressures are associated with reduced exercise capacity[2] and contribute to dyspnea on exertion. In acute decompensated HF (ADHF), increased pulmonary arterial pressure correlates with dyspnea at rest.[3]

Following the results of the ESCAPE (Evaluation Study of Congestive HF and Pulmonary Artery Catheterization Effectiveness) trial,[4] Doppler echocardiography is used with increasing frequency to diagnose PH in patients with HF. Previous studies have shown that echocardiographic diagnosis of elevated pulmonary artery systolic pressure (PASP) in hemodynamically stable outpatient HF patients is associated with increased risk.[5],[6]

The right ventricle (RV) can accommodate large changes in volume loading but has a limited contractile reserve to match increased afterload.[7] A progressive increase in afterload is a major cause of RV adaptation and ultimately, failure. The ability of the RV to adapt to an increase in pulmonary pressures may, therefore, be a vital determinate of clinical outcome as recently demonstrated in stable HF.[8] Despite the importance of PH in ADHF as well as progressive chronic HF, and the inextricable relationship of RV function with the pulmonary circulation, earlier studies in HF have only analyzed the impact of PH in isolation. Therefore, we aim to study the implications of PH in combination with RV function in patients admitted for HF in terms of prognosis and clinical management.


  Methodology Top


Study design

All patients admitted to the regional tertiary care center with cardiovascular imaging facilities in urban setting, with the primary diagnosis of HF entered a retrospective study. Eligible patients were those hospitalized with new-onset or worsening of preexisting HF as the primary cause of admission, or those with significant HF symptoms that developed during the hospitalization where HF was the primary discharge diagnosis. HF was diagnosed according to the American College of Cardiology/American Heart Association (ACC/AHA) stages of HF.[9] Secondary PH due to left-sided heart diseases such as left ventricular failure and valvular heart diseases were excluded. Criteria fulfilling PH groups of I (pulmonary arterial hypertension), III (PH due to lung disease), IV (thromboembolic PH), and V (PH due to unclear/multifactorial mechanisms) were included only.[10]

Echocardiography evaluation

All echocardiographic studies were performed during the hospital stay by experienced cardiologists. The analysis of estimated PASP, RV function (TAPSE, Global RV Function by eyeballing and fractional area change), and left ventricular (LV) function was carried out without knowledge of the patient outcome.

Echocardiograms were performed in multiple views to obtain the optimal appearing tricuspid regurgitation jet. The estimated PASP was calculated as the sum of the peak systolic pressure gradient across the tricuspid valve (approximated by modified bernoulli equation) and right atrial pressure (RAP).[11] RAP was estimated according to the size and respiratory variation of the inferior vena cava diameter in the subcostal view with the use of established criteria.[11] For study purpose, PASP >50 mmHg was considered.

Study endpoint

The primary endpoint of the study was all-cause mortality after hospital discharge. After hospital discharge, clinical endpoint information was acquired by telephonic follow-up for survival statistics and by reviewing the hospital records for major clinical events if the patient had been rehospitalized.


  Results Top


During the study, 400 patients who met the inclusion criteria were reviewed. Of these, PASP could be estimated in 306 patients (81.5%). In the 306 patients with measurable PASP, PH was present in 134 patients (43.8%) and RV dysfunction in 129 patients (42.2%). The majority of patients with RV dysfunction had PH (58.1%).

Effects of pulmonary artery systolic pressure and right ventricular function on mortality

During the 3-year follow-up period, 91 patients (29.7%) died. The proportional mortality rate in 3D pie charts of the 4 study subgroups is shown in [Figure 1]. Patients with normal RV function and without PH had the lowest mortality. There was a marked increase in the risk of mortality in patients with both RV dysfunction and PH, and patients with normal RV function and PH had an intermediate risk. Notably, patients with RV dysfunction but without PH were not at increased risk for mortality.
Figure 1: Displays pie charts of proportional mortality in patient subpopulations with color-coded years. The lowest mortality is shown in patients with neither pulmonary hypertension nor right ventricular dysfunction; patients with either pulmonary hypertension (PH) or right ventricular dysfunction (RVD) have intermediate mortality risk; while patients with both pulmonary hypertension and right ventricular dysfunction have highest mortality risk

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  Discussion Top


This study shows that PH as assessed by Doppler echocardiography is present in >40% of patients with HF. PH was a powerful independent predictor of mortality in patients with both normal RV function and RV dysfunction.[11] PH was strongly associated with RV dysfunction and was a major determinant of mortality in this subgroup. Our findings reaffirm the fact that elevated PASP in elderly is associated with high mortality.[12] When mortality risk was evaluated using baseline characteristics such as age, body mass index, smoking addiction history, chronic lung disease, and NT-proBNP (N-terminal pro b-type natriuretic peptide), the combined assessment of PH and RV function was clinically meaningful, indicating fundamental hemodynamic information represents disease severity rather than reflecting other comorbidities.

PH as diagnosed by Doppler-derived estimated PASP is highly prevalent among patients with chronic HF. Hemodynamic worsening that includes increasing pulmonary arterial pressure is characteristic of ADHF. Thus, the estimation of PASP may be warranted in the standard assessment of ADHF.[13] The RV can accommodate large changes in volume loading, but has a limited contractile reserve to match increased impedance to ejection. Therefore, compared with the left ventricle, the RV demonstrates a heightened sensitivity to afterload change. Thus, regardless of the initial mechanism for RV dysfunction, an increase in RV afterload through the development of pulmonary arterial hypertension promotes RV remodeling and failure. It should be remembered that although long axis function of the RV is a useful clinical measurement, it does not reflect overall RV function since it does not represent the other parts of the ventricle, including the right ventricular (RV) outflow tract, which is the most sensitive compartment to changes in pulmonary circulation resistance and pressures.

The Indian subcontinent has a major population with chronic obstructive pulmonary disease, tuberculosis, allergic airway diseases, and thromboembolism. These conditions can aggravate the severity of PH and RV dysfunction over a period of time and progression of the underlying pathological process. In the present study, the profound effect of PH on the RV translated into major differences in mortality. Although PH was associated with increased mortality in patients with normal RV function, there was a striking increase in mortality in patients with both PH and RV dysfunction. Signs of pulmonary and systemic congestion were present in proportional to PH only. In contrast, RV dysfunction without PH did not incur increased mortality risk. This finding suggests the dysfunctional RV can compensate in the absence of pressure overload.


  Conclusion Top


PH has drastic effects on RV structure and intrinsic myocardial function, significantly disturbing its ejection time relations and overall pump performance. PH, as assessed by echocardiography, is a common finding in ADHF as well as chronic HF and is frequently associated with RV dysfunction. PH and RV function provide an independent and prognostic evaluation as compared to other predictors of outcome.

Remarkably, the compounding effect of PH & RV dysfunction is detrimental in terms of high morbidity rates and mortality outcomes. Management strategies should focus on identifying precipitating factors, restoring oxygenation and hemodynamic stability, and employing pharmacologic therapies and/or procedures shown to improve outcome. Therefore, the estimation of PASP by echocardiography may be warranted in the standard assessment of ADHF and chronic HF patients and is especially important in the presence of RV dysfunction. Early identification of such changes might help in classifying patients who need specific therapy early on in the disease process including medications with proven mortality benefits.

Future directions

A thorough assessment of RV function and geometry has been studied less in view of the predominance of ischemic heart diseases and left ventricular dysfunction. However, the detailed imaging research is needed to better define normal RV parameters in terms of function and geometry in relation to hemodynamics of PH affecting RV anatomy and physiology. A clear picture of parameters would help in determining which measurements are the best predictors of early RV failure such as RV wall thickness, muscle perfusion, or metabolic activity. Ideally, a combination of approaches would be used to evaluate right heart function, including imaging techniques (Doppler echocardiography, computed tomography, magnetic resonance imaging, and positron emission tomography), implanted continuous monitoring devices, and electrophysiology. Collaboration with the cardiac imaging institutes and biomedical engineering institutes to promote the development of imaging methods to study RV function and dysfunction should be encouraged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalogeropoulos AP, Vega JD, Smith AL, Georgiopoulou VV. Pulmonary hypertension and right ventricular function in advanced heart failure. Congest Heart Fail 2011;17:189-98.  Back to cited text no. 1
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2.
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Solomonica A, Burger AJ, Aronson D. Hemodynamic determinants of dyspnea improvement in acute decompensated heart failure. Circ Heart Fail 2013;6:53-60.  Back to cited text no. 3
    
4.
Binanay C, Califf RM, Hasselblad V, O'Connor CM, Shah MR, Sopko G, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: The ESCAPE trial. JAMA 2005;294:1625-33.  Back to cited text no. 4
    
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Lam CS, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, Redfield MM, et al. Pulmonary hypertension in heart failure with preserved ejection fraction: A community-based study. J Am Coll Cardiol 2009;53:1119-26.  Back to cited text no. 5
    
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Damy T, Goode KM, Kallvikbacka-Bennett A, Lewinter C, Hobkirk J, Nikitin NP, et al. Determinants and prognostic value of pulmonary arterial pressure in patients with chronic heart failure. Eur Heart J 2010;31:2280-90.  Back to cited text no. 6
    
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Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular function in cardiovascular disease, part II: Pathophysiology, clinical importance, and management of right ventricular failure. Circulation 2008;117:1717-31.  Back to cited text no. 7
    
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Ghio S, Temporelli PL, Klersy C, Simioniuc A, Girardi B, Scelsi L, et al. Prognostic relevance of a non-invasive evaluation of right ventricular function and pulmonary artery pressure in patients with chronic heart failure. Eur J Heart Fail 2013;15:408-14.  Back to cited text no. 8
    
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr., Colvin MM, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the Management of heart failure: A Report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the heart failure society of America. J Am Coll Cardiol 2017;70:776-803.  Back to cited text no. 9
    
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Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol 2013;62:D34-41.  Back to cited text no. 10
    
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Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: A report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685-713.  Back to cited text no. 11
    
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Steiner J, Wu WC, Jankowich M, Maron BA, Sharma S, Choudhary G, et al. Echocardiographic predictors of mortality in patients with pulmonary hypertension and cardiopulmonary comorbidities. PLoS One 2015;10:e0119277.  Back to cited text no. 12
    
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