Systolic pulmonary artery pressure threshold to define pulmonary and peripheral congestion in acute heart failure in absence of severe tricuspid regurgitation

Background and aims Pulmonary and/or peripheral venous congestion defines the clinical diagnosis of acute heart failure (AHF). However, the systolic pulmonary arterial pressure (sPAP) thresholds at which pulmonary (chest x-ray) and inferior vena cava (IVC) congestion occur are not well established. This study aimed to identify a cut-off value of sPAP that reliably indicates AHF. Methods and results We retrospectively included 380 consecutive patients hospitalized for AHF at an Italian referral centre, after excluding those with severe tricuspid regurgitation. Receiver operating characteristic (ROC) curve analysis and Youden's J statistic identified a threshold of sPAP ≥ 48.75 mmHg as the most accurate in predicting both pulmonary (sensitivity = 89.9%, specificity = 73%) and peripheral (sensitivity = 88.3%, specificity = 82.5%) fluid overload. The association between this sPAP threshold and both pulmonary and peripheral congestion was confirmed by chi-square testing ( p < 0.001) and multivariate logistic regression ( p < 0.001). After adjustment for confounders, sPAP ≥ 49 mmHg was independently associated with all-cause death or heart failure (HF) hospitalization (HR = 1.713; 95% CI 1.127–2.602; p = 0.012). Conclusions sPAP threshold of 49 mmHg identifies congestion with clinically useful accuracy—pulmonary (chest X-ray) congestion.