Why the study?
The diastolic pressure gradient has been proposed as the metric of choice for diagnosing pulmonary vascular changes in left heart disease, under the hypothesis that it is less sensitive to changes in left atrial pressure and stroke volume than the transpulmonary gradient.
Is the diastolic pressure gradient (DPG) less sensitive to dynamic changes in pulmonary capillary wedge pressure (PCWP) and stroke volume (SV) than the transpulmonary gradient (TPG) in patients with acute heart failure undergoing decongestive therapy?
Cohort (n=242)
Yes
Is the diastolic pressure gradient (DPG) less sensitive to dynamic changes in pulmonary capillary wedge pressure (PCWP) and stroke volume (SV) than the transpulmonary gradient (TPG) in patients with acute heart failure undergoing decongestive therapy?
Contrary to guideline assumptions, the diastolic pressure gradient (DPG) is just as sensitive to changes in left atrial pressure (PCWP) and resistance-compliance time as the transpulmonary gradient (TPG), and frequently yields negative values at high PCWP, limiting its reliability for diagnosing combined post- and pre-capillary pulmonary hypertension in acute heart failure.
PCWP reduction increases DPG similarly to TPG during acute HF decongestive therapy; challenges guideline assumptions on DPG stability and leaves diagnostic reliability open.
The diastolic pressure gradient (DPG) has been proposed as the metric of choice for the diagnosis of pulmonary vascular changes in left heart disease. We tested the hypothesis that this metric is less sensitive to changes in left atrial pressure and stroke volume (SV) than the transpulmonary gradient (TPG). We studied the effect of dynamic changes in pulmonary capillary wedge pressure (PCWP), SV, and pulmonary artery capacitance (PAC) on DPG and TPG in 242 patients with acute heart failure undergoing decongestive therapy with continuous hemodynamic monitoring. There was a close impact of PCWP reduction on TPG and DPG, with a 0.13 mmHg (95% confidence interval [CI] 0.07-0.19, P < 0.0001) and 0.21 mmHg (95% CI 0.16-0.25, P < 0.0001) increase for every 1 mmHg decrease in PCWP, respectively. Changes in SV had a negligible effect on TPG and DPG (0.19 and 0.13 mmHg increase, respectively, for every 10-mL increase in SV). Heart rate was positively associated with DPG (0.41-mmHg increase per 10 BPM [95% CI 0.22-0.60, P < 0.0001]). The resistance-compliance product was positively associated with both TPG and DPG (2.65 mmHg [95% CI 2.47-2.83] and 1.94 mmHg [95% CI 1.80-2.08] for each 0.1-s increase, respectively). In conclusion, DPG is not less sensitive to changes in left atrial pressure and SV compared with TPG. Although DPG was not affected by changes in PAC, the concomitant increase in the resistance-compliance product increases DPG.
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Aronson et al. (2018) conducted a cohort in Acute heart failure with reduced ejection fraction (HFrEF) and pulmonary hypertension due to left heart disease (PH-LHD) (n=242). Dynamic changes in pulmonary capillary wedge pressure (PCWP), stroke volume (SV), and pulmonary artery capacitance (PAC) during decongestive therapy (nesiritide or nitroglycerin plus diuretics) was evaluated on Change in diastolic pressure gradient (DPG) per 1 mmHg decrease in pulmonary capillary wedge pressure (PCWP) (MD 0.21 mmHg increase per 1 mmHg PCWP decrease, 95% CI 0.16-0.25, p=<0.0001).
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