RESULTADOS DE LA ENTREVISTA A DIRECTIVOS
6. CONCLUSIONES Y RECOMENDACIONES GENERALES
The key echocardiographic factors implicated in the development of PH in HF patients are left heart variables associated with increased pulmonary venous pressure.7 These factors include markers of elevated LV filling pressure and parameters of mitral regurgitation as demonstrated by most studies.4,5,8-10
Echocardiographic markers of elevated LV filling pressures and LV diastolic function which include LAVI and E/e´ ratio correlated significantly and positively with both PASP and mPAP in this study (p<0.001). This was also significant on multivariate analysis. This suggests that
worsening LV diastolic function and increasing LV filling pressures are independently
91
associated with increasing PASP and mPAP. This finding is similar to the reports of most other studies of PH in HF patients.4,5,8,9
Mitral regurgitant volume correlated positively with PASP and mPAP. This suggests that
worsening mitral regurgitation in the study population was associated with increasing pulmonary artery pressures. However, this finding was not significant on multivariate analysis. Enriquez-Sarano et al9 also found a significant correlation between mitral regurgitant volume and PASP.
Damy et al8 reported a significant independent relationship between worsening mitral
regurgitation class and an elevated PASP. In the initial phase of chronic mitral regurgitation, the left atrium enlarges and is able to accommodate a large regurgitant volume without significant elevation in mean left atrial pressure.49 Subsequently, chronic mitral regurgitation results in maladaptive increase in LV dimensions, increase in systolic wall stress, progressive decline in LV contractile function, elevation of left atrial pressure, and thus worsening pulmonary hypertension.49
The relationship between LV ejection fraction (LVEF) and PH is less clear in view of the conflicting data reported in various studies.4,5,6,8,9,47 In this study, LVEF correlated negatively with both PASP and mPAP. This suggests that worsening LV systolic function was associated with increasing PASP and mPAP. The association of LVEF with mPAP was also significant on multivariate analysis. In a similar study, Damy et al8 also found an independent association between LV systolic dysfunction and PASP elevation. Enriquez-Sarano et al9 and Miller et al47 both reported a significant negative correlation between LVEF and PASP on univariate analysis amongst HFrEF patients. Karaye et al6 did not find a significant correlation between LVEF and mPAP, perhaps due to the smaller sample size of 80 since their PH subjects had a lower mean LVEF which was close to significance (p = 0.053). The community studies of Lam et al5 and
92
Bursi4 et al in an HFpEF and mixed HF population respectively did not find a significant
association between LVEF and PASP. The reason for the disparity could be the heterogeneity of HF types in these studies. The association of worsening LVEF and PH is likely to be seen in studies of isolated or predominant HFrEF populations. The present study had a predominant HFrEF frequency of 66.7%. The study Damy et al also had a majority HFrEF population of 74.3%. Isolated HFrEF studies of Enriquez-sarano et al9 and Miller et al47 both found significant associations between LVEF and PH. Other studies5,6 that did not find a significant association had isolated or a significant number of HFpEF subjects.
PH of any cause is associated with compensatory and maladaptive changes of the right heart.7,38 In this study, all the parameters of RV structure (RVOT, ERV, RV basal and RV wall thickness dimensions) and function (TAPSE and Eccentricity index) correlated significantly with both PASP and mPAP. This finding highlights the importance of properly assessing the right side of heart which can help to characterize patients with borderline Doppler derived pulmonary artery pressure measurements.12,13
93 CHAPTER 6 CONCLUSIONS
1. Pulmonary hypertension is fairly common in our heart failure population occurring in 38.8 - 61.6% of cases.
2. Heart failure subjects with pulmonary hypertension are more likely to be male with a lower BMI, systolic blood pressure and a worse NYHA functional class compared with subjects without pulmonary hypertension.
3. Hypertensive heart disease is the commonest cause of heart failure in this environment but it is less frequent in HF patients with PH, while dilated cardiomyopathy and valvular heart disease are more frequent in them.
4. The presence of PH in this heart failure population is significantly associated with higher LV filling pressures, more severe mitral regurgitation, poorer LV systolic function and worse RV remodeling.
5. Clinical parameters are not independently associated with pulmonary artery pressures in this study population.
94
6. In this heart failure population, increasing LV filling pressures, worsening mitral regurgitation, LV systolic function and RV remodeling are associated with increasing pulmonary artery pressures.
7. The left atrial volume index and E/e´ ratio are independently associated with pulmonary artery systolic pressure, while LV ejection fraction, left atrial volume index and E/e´ ratio are independently associated with mean pulmonary artery pressure.
RECOMMENDATIONS
1. Echocardiographic screening for pulmonary hypertension should be done in all heart failure patients in order to identify those at high risk who require aggressive optimization of standard therapy.
2. A large prospective study is required in order to determine the prognostic significance of pulmonary hypertension in our environment.
3. Heart failure subjects with pulmonary hypertension should be enrolled in randomized control trials in order to clarify the unmet needs of specific therapy for this patient group.
95 LIMITATIONS
1. This was a hospital based study; hence the true prevalence of pulmonary hypertension in HF subjects could not be obtained.
2. The cross-sectional design of this study could only seek for correlates of pulmonary hypertension without implying their causality.
3. Echocardiographic measurement of pulmonary pressures can be a source of error especially when a nonparallel intercept angle is maintained between the ultrasound beam and TR jet. This limitation was minimized by proper echocardiographic technique as previously described. This method is also well validated by several studies with RHC.51-53
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APPENDIX I
CLINICAL AND ECHOCARDIOGRAPHIC AND CORRELATES OF PULMONARY HYPERTENSION IN PATIENTS WITH HEART FAILURE
DATA ENTRY FORM
STUDY NUMBER--- MOBILE PHONE--- RECRUITMENT DATE---
PERSONAL DATA
NAME:__________________________ AGE___________yrs
SEX: Male_____Female_______ OCCUPATION____________________
MARITAL STATUS: _________________ RELIGION:_______________________
HISTORY OF HEART FAILURE
SOB ORTHOPNOEA PND
FATIGUE LEG SWELLING COUGH
MEDICAL HISTORY/ AETIOLOGY OF HF
HYPERTENSION Yes No DURATION:____________________________
DIABETES Yes No DURATION:____________________________
DCM: Yes No HCM: Yes No
Rheumatic Heart Dx: Yes No Previous MI: Yes No
Ischaemic heart dx: Yes No No. of previous hospitalizations for HF______
Peripartal cardiomyopathy: Yes No Duration of Heart Failure_________________
GENERAL EXAM
HEIGHT___________M WEIGHT__________KG
BMI____________ PEDAL OEDEMA
BSA____________
CVS EXAM
109
PULSE____________ BP_______________________
JVP _____________ APEX BEAT________________
HEART SOUNDS ______________ S3 Loud P2
OTHER EXAMINATION
RALES:_______________________ HEPATOMEGALY:________________
RR:_____________ ASCITES:_________________
FRAMINGHAM CRITERIA CHECKLIST MAJOR
PND JVP RALES CARDIOMEGALY ACUTE PULM OEDEMA
S3 HEPATOJUGULAR REFLUX
TOTAL MAJOR
MINOR EXTREMI TY OEDEMA
NIGHT COUGH
DYSPNOEA ON
EXERTION
HEPATO MEGALY
PLEURAL EFFUSSI ON
TACHYCA RDIA
TOTAL MINOR
HEART FAILURE- 2 MAJOR OR 1 MAJOR & 2 MINOR
CLINICAL HEART FAILURE: YES NO
NYHA CLASS: A)I B)II C)III D)IV