Key result
Haemodynamic risk assessment in PAH outperforms noninvasive tools, which lose prognostic value after age 65.
Why the study?
Noninvasive parameters recommended by guidelines to define a low-risk profile in PAH are influenced by age, prompting investigation into the impact of age on treatment response and haemodynamic-based risk assessments.
Does age influence the prognostic accuracy of haemodynamic versus noninvasive risk assessments in patients with pulmonary arterial hypertension?
Cohort (n=794)
No
Does age influence the prognostic accuracy of haemodynamic versus noninvasive risk assessments in patients with pulmonary arterial hypertension?
Haemodynamic risk assessment is less influenced by age than noninvasive tools and serves as a valid therapeutic target for older PAH patients who fail to meet noninvasive low-risk criteria.
Haemodynamic risk assessment warrants consideration in elderly PAH; leaves open whether it improves outcomes over noninvasive tools.
Background: In patients with pulmonary arterial hypertension (PAH), current European guidelines recommend achieving a low-risk profile, primarily based on World Health Organization functional class (WHO-FC), 6-min walk distance (6MWD) and natriuretic peptides. However, these noninvasive parameters are influenced by age. We investigated the impact of age on treatment response and evaluated the prognostic role of haemodynamic-based risk assessments. Methods: Treatment-naïve PAH patients from a single-centre registry were included, stratified by age. Clinical and functional measures and haemodynamics were assessed at baseline and after initial PAH-targeted therapy. Prognostic discrimination was performed using noninvasive (European Society of Cardiology/European Respiratory Society 4-strata, REVEAL Lite 2) and haemodynamic-based risk models (including a purely haemodynamic - RHC - risk tool) with Cox regression and C-statistics. Results: 794 PAH patients were enrolled. Elderly individuals exhibited worse WHO-FC, higher levels of natriuretic peptides and shorter 6MWD, despite lower right ventricular (RV) afterload, likely due to comorbidities and worse RV function. Improvement of WHO-FC, levels of natriuretic peptides and 6MWD is lower in the elderly, despite comparable haemodynamic changes across the age groups. In older patients, noninvasive risk tools overestimated RHC risk tool severity and demonstrated a reduced prognostic accuracy. In patients aged >65 years reaching a low-risk haemodynamic profile, noninvasive risk tools were of no added prognostic value. Conversely, haemodynamics provided independent prognostic information in younger patients. Conclusions: Haemodynamics is less influenced by age than noninvasive risk assessment and is of added prognostic value to noninvasive assessment in younger patients. Achieving a low-risk haemodynamic profile can be a valid therapeutic target when noninvasive criteria are not met in patients aged >65 years.
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Dardi et al. (2025) conducted a cohort in Pulmonary arterial hypertension (n=794). Haemodynamic-based risk assessment vs. Noninvasive risk assessment was evaluated on Prognostic discrimination of risk models. In 794 patients with PAH, haemodynamic-based risk assessment was less influenced by age than noninvasive tools, which provided no added prognostic value in patients aged >65 years.
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