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. 2025 Feb;167(2):573-584.
doi: 10.1016/j.chest.2024.09.013. Epub 2024 Sep 26.

Prognostic Relevance of Tricuspid Annular Plane Systolic Excursion to Systolic Pulmonary Arterial Pressure Ratio and Its Association With Exercise Hemodynamics in Patients With Normal or Mildly Elevated Resting Pulmonary Arterial Pressure

Teresa John  1 , Alexander Avian  2 , Nikolaus John  1 , Antonia Eger  1 , Vasile Foris  3 , Katarina Zeder  3 , Horst Olschewski  3 , Manuel Richter  4 , Khodr Tello  4 , Gabor Kovacs  3 , Philipp Douschan  5
Affiliations

Prognostic Relevance of Tricuspid Annular Plane Systolic Excursion to Systolic Pulmonary Arterial Pressure Ratio and Its Association With Exercise Hemodynamics in Patients With Normal or Mildly Elevated Resting Pulmonary Arterial Pressure

Teresa John et al. Chest. 2025 Feb.

Abstract

Background: Echocardiographic tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary arterial pressure (sPAP) ratio is a noninvasive surrogate for right ventricle (RV)-pulmonary arterial (PA) coupling. It has been related to outcome in patients with moderate to severe pulmonary hypertension (PH).

Research question: Is RV-PA coupling of prognostic relevance in patients with suspected PH, but only normal or mildly elevated mean pulmonary arterial pressure (mPAP), and is it associated with impaired exercise capacity and exercise hemodynamics?

Study design and methods: Patients with mPAP of < 25 mm Hg who underwent echocardiography and exercise right heart catheterization in our PH clinic were analyzed retrospectively. Mild PH was defined as mPAP of 21 to 24 mm Hg and exercise PH (EPH) was defined as a mPAP to cardiac output (CO) slope of > 3 mm Hg/L/min. Multivariate analysis was performed to identify independent predictors for clinical worsening (CW), defined by disease-related hospitalization, transplantation, or death.

Results: Two hundred thirty-seven patients (155 female with median age, 64 years [interquartile range (IQR), 54-73 years]; no PH: n = 147; mild PH: n = 90; EPH: n = 202) were included. During the observation time of 63 months (IQR, 29-104 months), 36 patients died and 126 clinical worsening events occurred. TAPSE to sPAP ratio was an age- and sex-independent predictor of mortality (hazard ratio [HR], 0.09; 95% CI, 0.01-0.62; P = .014) and clinical worsening (HR, 0.05; 95% CI, 0.35-0.78; P = .002). TAPSE to sPAP ratio also was correlated significantly to 6-min walk distance (r = 0.33; P < .001) and exercise hemodynamics (mPAP to CO slope: rρ = -0.56; P < .001). The best multivariate predictive model for clinical worsening in this population consisted of TAPSE to sPAP ratio (HR, 0.71; 95% CI, 0.53-0.95; P = .021), N-terminal pro-brain natriuretic peptide (HR, 1.15; 95% CI, 0.99-1.34; P = .065), and 6-min walk distance (HR, 0.998; 95% CI, 0.995-1.00; P = .042).

Interpretation: Our results indicate that in patients with suspected PH, but normal or only mildly elevated resting mPAP, TAPSE to sPAP ratio is an independent predictor of outcome. In addition, it is associated significantly with exercise capacity and exercise hemodynamics and may be a helpful tool in the prediction of future clinical worsening of this patient population.

Keywords: RV-PA coupling; TAPSE to sPAP ratio; exercise hemodynamics; exercise pulmonary hypertension; mild pulmonary hypertension; prognosis.

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Conflict of interest statement

Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: T. J. reports personal fees and nonfinancial support from Janssen, Ferrer, MSD, and Boehringer Ingelheim and personal fees from Roche, outside the submitted work; V. F. reports personal fees and nonfinancial support from Janssen and Chiesi, and nonfinancial support from Boehringer Ingelheim, AstraZeneca, MSD, and Ferrer, outside the submitted work; K. Z. reports grants from Max Kade Foundation, Cardiovascular Medical Research, and Education Fund, personal fees from MSD, Janssen, and Ferrer, and other from Ferrer, outside the submitted work; H. O. reports grants and personal fees from MSD and Iqvia, personal fees from Janssen, Ferrer, Mondial, and MedUpdate, grants and nonfinancial support from Ludwig Boltzmann Institute for Lung Vascular Research, outside the submitted work; G. K. reports grants, personal fees and nonfinancial support from Janssen, Boehringer-Ingelheim, MSD, AOP, and Chiesi, outside the submitted work, personal fees from Bayer, Ferrer, GSK, and AstraZeneca; P. D. reports personal fees from Actelion, Janssen, Ferrer, GSK, and Chiesi and nonfinancial support from Actelion, AstraZeneca, Boehringer Ingelheim, GSK, MSD, Novartis, Menarini, Ferrer and Chiesi, outside, the submitted work. None declared (A. A., N. J., A. E., M. R., K. T).

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