Elevated pulmonary artery pressure by Doppler echocardiography predicts hospitalization for heart failure and mortality in ambulatory stable coronary artery disease: the Heart and Soul Study

Abstract

Objectives: We compared the predictive ability of tricuspid regurgitation (TR) and end-diastolic pulmonary regurgitation (EDPR) gradients in outpatients with coronary artery disease.

Background: The TR and EDPR gradients, in conjunction with right atrial pressure, provide Doppler estimates of pulmonary artery systolic and diastolic pressures. We hypothesized that increases in TR or EDPR gradients in stable coronary artery disease would predict heart failure (HF) hospitalization or cardiovascular (CV) death.

Methods: We measured TR and EDPR gradients in 717 adults with completed outcome adjudications who were recruited for the Heart and Soul Study. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for HF hospitalization, CV death, all-cause death, and the combined end point. Multivariate adjustments were made for age, gender, race, history of CV or pulmonary disease, functional class, and left ventricular ejection fraction.

Results: There were 63 HF hospitalizations, 19 CV deaths, and 86 all-cause deaths at the 3-year follow-up. There were 466 measurable EDPR gradients and 573 measurable TR gradients. Age-adjusted ORs for EDPR >5 mm Hg predicted HF hospitalization (2.7, 95% CI 1.3 to 5.5, p = 0.006), all-cause death (2.5, 95% CI 1.4 to 4.4, p = 0.002), and HF hospitalization or CV death (2.7, 95% CI 1.4 to 5.2, p = 0.004). Age-adjusted OR for TR >30 mm Hg predicted HF hospitalization (3.4, 95% CI 1.9 to 6.2, p < 0.0001) and HF hospitalization or CV death (3.0, 95% CI 1.7 to 5.3, p = 0.0001). Multivariate adjusted OR per 5-mm Hg incremental increases in EDPR predicted HF hospitalization or CV death (1.9, 95% CI 1.01 to 3.6, p = 0.046) and all-cause death (1.7, 95% CI 1.05 to 2.8, p = 0.03). Multivariate adjusted OR per 10-mm Hg incremental increases in TR predicted HF hospitalization or CV death (1.6, 95% CI 1.1 to 2.4, p = 0.008).

Conclusions: Increases in EDPR or TR gradients predict HF hospitalization or CV death among ambulatory adults with coronary artery disease.

Figure 1. Tricuspid Regurgitation Gradient

On color flow Doppler signal, the highest tricuspid regurgitation gradient from parasternal, apical, or subcostal views is recorded. The apical view is shown.

Figure 2. End-Diastolic Pulmonary Regurgitation Gradient

On color Doppler signal from the parasternal short axis, the end-diastolic pulmonary regurgitation gradient is measured at the first peak deflection of the QRS on electrocardiogram, corresponding with termination of reverse flow across the pulmonic valve.

Figure 3. Percent Hospitalization for HF or CV Death by Elevations in EDPR or TR Gradients

Percent of patients with the combined outcome (heart failure [HF] hospitalization or cardiovascular [CV] death) by elevations in end-diastolic pulmonary regurgitation (EDPR) or tricuspid regurgitation (TR) gradients.