Impact of the 2022 ESC/ERS guidelines on diagnosing pulmonary hypertension in heart failure with reduced ejection fraction patients undergoing elective right heart catheterization

Background/Introduction Pulmonary hypertension (PH) is an important comorbidity in heart failure (HF). In 2022, new ESC/ERS guidelines on the diagnosis and treatment of pulmonary hypertension were published [1]. Cut-off value of mean pulmonary artery pressure (mPAP) had changed from ≥ 25 mmHg to > 20 mmHg for the diagnosis of PH [1,2]. Purpose The goal of the study was to estimate the significance and characteristics of groups of patients with mPAP 21-24 mmHg - who, according to new recommendations are diagnosed with PH. Methods The study group comprised 564 consecutive patients with HF with reduced ejection fraction (HFrEF) undergoing elective RHC. PH was diagnosed according to the ESC/ERS 2022 guidelines: when mPAP > 20 mmHg. Groups with mPAP ≥ 25 mmHg, mPAP 21-24 mmHg and ≤ 20 mmHg (without PH) were characterized and compared by Chi2 and ANOVA tests. Results The mean age of the whole group was 51.9 ± 11.3 years, 15.4% were women and the mean left ventricular ejection fraction (LVEF) was 21.0 ± 7.0%. The NYHA functional class IV was observed in 14.5%, class III in 55.9%, and class I or II in 29.6%. PH was diagnosed in 78.7% of cases according to the 2022 ESC/ERS Guidelines, compared to 68.4% according to the previous cut-off value. Comparing all three groups, LVEF was lower (20.3 ± 6.5 %), while NT-pro-BNP was higher [2918 (IQR 1630-5864) ng/mL], and NYHA class III and IV more often (75.3 %) in patients with mPAP ≥ 25 mmHg than in patients without PH [23.2 ± 7.3%; 1089 (IQR 461-2632) ng/mL and 53.9%, respectively]. The cohort with mPAP 21-24 mmHg had intermediate values of these parameters [21.2 ± 8.2%; 2235 (IQR 1195-4463) ng/mL; and 66.6%, respectively). The differences were statistically significant: the one-way ANOVA p-value was <0.001 for LVEF, 0.002 for NT-pro-BNP, and Chi2 p for NYHA class <0.001. There were no significant differences in age (p=0.53), sex (p=0.10) and BMI (p=0.26). Conclusions Approximately one-third of HFrEF patients undergoing RHC without the diagnosis of PH according to previous ESC/ERS guidelines (2015) [2] may have had PH according to the most recent guidelines (2022) [1] with reduced mPAP cut-off. It is important to use current guidelines in clinical practice to not miss the diagnosis of PH in HFrEF patients, which can influence the management and prognosis.