Clinical Investigation
Echocardiographic Parameters Associated with Outcomes in Various Diseases
Right Atrial Pressure Is Associated with Outcomes in Patients with Heart Failure and Indeterminate Left Ventricular Filling Pressure

https://doi.org/10.1016/j.echo.2020.05.027Get rights and content

Highlights

  • •

    mRAP is a marker of LVFP in HF without predominant RV disease, severe TR, or MR.

  • •

    Echocardiographic IP is a common finding in hospitalized patients with HF.

  • •

    Echocardiographic mRAP is associated with outcome in IP but not NP or HP patients.

  • •

    Current algorithms for LVFP determination should include mRAP in IP cases.

Background

In a significant proportion of patients with left-sided heart failure (HF), left ventricular filling pressure (LVFP) may not be estimated using echocardiography, so filling pressure status may remain indeterminate. In these patients, mean right atrial pressure (mRAP) has been suggested as a surrogate of LVFP. The aim of this study was to determine whether high mRAP has prognostic value in patients with HF with indeterminate pressure (IP) and whether mRAP-based reclassification of patients with IP has an impact on outcomes.

Methods

A cohort of 465 patients hospitalized with HF was retrospectively studied and divided into groups with normal pressure (n = 102), high pressure (n = 265), and IP (n = 98). A composite end point of all-cause mortality and HF rehospitalization was evaluated after a median follow-up duration of 2.5 years.

Results

There were 282 events in the entire population (53 in the normal pressure group, 173 in the high pressure group, and 56 in the IP group; P = .047). High mRAP was independently associated with outcome only in patients with IP (hazard ratio, 2.72; 95% CI, 1.25–5.9; P = .012). Evaluation of LVFP after mRAP-based reclassification of patients with IP resulted in higher risk stratification capability than current recommendations alone (log-rank χ2 = 15.057 vs 8.148).

Conclusions

In patients with inconclusive determination of LVFP, echocardiographic estimation of mRAP is associated with outcomes. This finding corroborates previous observation of mRAP as a surrogate marker of elevated LVFP in left-sided HF and suggests its use in clinical practice.

Section snippets

Population

A cohort of 598 consecutive adult patients admitted to our hospital who underwent echocardiography for suspected HF from January 2016 to December 2017 was evaluated. At hospital discharge, 496 patients had confirmed diagnoses of HF and were considered for the study (diagnoses not confirmed as HF were pulmonary embolism in 42 patients, chronic obstructive pulmonary disease exacerbation in 29 patients, pneumonia and sepsis in 26 patients, and cardiac tamponade in five patients). At the time of

Patient Characteristics

Patient characteristics are reported in Supplemental Table 1 for the overall cohort and subgroups of patients with LVEFs < 50% and ≥50%. Patients with different LVEFs differed on a number of variables. Patients with LVEFs < 50% had more ischemic etiology and coronary artery disease and less arterial hypertension, higher levels of NatPs, higher heart rates at admission and during transthoracic echocardiography, higher LV end-diastolic volume and end-systolic volume, lower SVI and cardiac index,

Discussion

Our study shows that the noninvasive estimation of mRAP using echocardiography may help stratify prognosis in the subset of patients with IP, whereas it does not do so in patients with current guideline-determined LVFP. In addition, reclassification of patients with IP according to noninvasive mRAP estimation allows a net prognostic distinction between patients with HF with NP and HP, with the latter having worse outcomes.

Conclusion

When guideline-recommended estimation of LVFP is inconclusive, echocardiographic estimation of RAP as a surrogate marker of LVFP can predict outcomes and therefore may be incorporated in the algorithm for estimating LVFP.

References (20)

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Conflicts of Interest: None.

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2020 Published by Elsevier Inc. on behalf of the American Society of Echocardiography.