Key result
Severe PH in aortic stenosis linked to ~3-fold higher all-cause mortality vs no PH.
Why the study?
The significance of pulmonary hypertension complicating aortic stenosis is poorly characterised.
Does the severity of pulmonary hypertension influence mortality in adults with moderate or greater aortic stenosis?
Cohort (n=14,980)
Yes
Does the severity of pulmonary hypertension influence mortality in adults with moderate or greater aortic stenosis?
Hazard Ratio: 2.94 (95% CI 2.65–3.27)
Absolute Event Rate: 76% vs 26.5%
p-value: p=<0.0001
Pulmonary hypertension is common in patients with moderate or greater aortic stenosis, and even borderline-mild elevations in pulmonary pressures (eRVSP >35 mm Hg) are associated with significantly increased mortality.
May refine mortality risk stratification in aortic stenosis from mild pulmonary hypertension onward; leaves open whether targeted therapy improves outcomes.
OBJECTIVE: The significance of pulmonary hypertension (PHT) complicating aortic stenosis (AS) is poorly characterised. In a large cohort of adults with at least moderate AS, we aimed to describe the prevalence and prognostic importance of PHT in such patients. METHODS: In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AS were included (n=14 980). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 2.6 years, IQR 1.0-4.6 years). RESULTS: Subjects were aged 77±13 years and 57.4% were female. Overall, 2049 (13.7%), 5085 (33.9%), 4380 (29.3%), 1956 (13.1%) and 1510 (10.1%) patients had no (eRVSP<30.00 mm Hg), borderline (30.00-39.99 mm Hg), mild (40.00-49.99 mm Hg), moderate (50.00-59.99 mm Hg) and severe PHT (>60.00 mm Hg), respectively. An echocardiographic phenotype was evident with worsening PHT, showing rising E:e' ratio and right and left atrial sizes(p<0.0001, for all). Adjusted analyses showed that the risk of long-term mortality progressively rose as eRVSP level increased (HR 1.14-2.94, borderline to severe PHT, p<0.0001 for all). A mortality threshold was identified in the 4th decile of eRVSP categories (35.01-38.00 mm Hg; HR 1.19, 95% CI 1.04 to 1.35), with risk progressively increasing through to the 10th decile (HR 2.86, 95% CI 2.54 to 3.21). CONCLUSIONS: In this large cohort study, we find that PHT is common in ≥moderate AS and mortality increases as PHT becomes more severe. A threshold for higher mortality lies within the range of 'borderline-mild' PHT. TRIAL REGISTRATION NUMBER: ACTRN12617001387314.
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Ratwatte et al. (2023) conducted a cohort in Aortic stenosis (n=14,980). Pulmonary hypertension (eRVSP levels) vs. No pulmonary hypertension (eRVSP <30 mm Hg) was evaluated on All-cause mortality (HR 2.94, 95% CI 2.65 to 3.27, p=<0.0001). In adults with moderate or greater aortic stenosis, severe pulmonary hypertension was associated with a significantly increased risk of long-term all-cause mortality compared to no pulmonary hypertension (HR 2.94).
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