The prognostic utility of the pulmonary artery pulsatility and aortic pulsatility index in patients with heart failure: A systematic review

Heart failure (HF) continues to pose a major burden worldwide, and risk stratification is important to guide management. Hemodynamic indices such as the pulmonary artery pulsatility index (PAPI) and aortic pulsatility index (API) have gained attention as potential prognostic tools, but their role is still not well established. We conducted a systematic review to assess the prognostic role of PAPI and API in HF patients. We systematically searched PubMed, Web of Science, Scopus, and Cochrane Library for studies assessing PAPI and API in adults (≥18 years) with HF. We included cohort studies and randomized trials reporting outcomes such as mortality, hospitalization, left ventricular assist device implantation, or heart transplantation. Of 601 studies identified, 12 met the inclusion criteria, comprising 3681 patients. Across different HF populations, lower PAPI values were consistently associated with worse outcomes, with reported cutoffs ranging from ≤1.9 in cardiogenic shock to around ≤2.8–2.95 in broader HF populations, and up to ≤3.65 in advanced HF. Aortic pulsatility index showed a similar pattern, but with more consistent performance: values <1.45 were linked to mortality or rapid progression to advanced therapies, while values >2.9 were associated with better event-free survival. In studies that evaluated both indices, API generally showed stronger prognostic value. Overall, PAPI and API provide clinically useful prognostic information, particularly in advanced HF patients undergoing invasive hemodynamic assessment, though further large-scale prospective studies are needed to better define their role.