Longitudinal changes in echocardiographic estimate of pulmonary capillary wedge pressure improve outcome prediction in chronic heart failure with reduced ejection fraction

Abstract Background A novel echocardiographic algorithm for estimating pulmonary capillary wedge pressure (ePCWP) and pulmonary vascular resistance (ePVR) has been recently validated against right heart catheterization,1 demonstrating optimal diagnostic accuracy and strong prognostic value in a large cohort of patients with the suspicion of pulmonary hypertension, including heart failure (HF) patients with left ventricular ejection fraction (LVEF) 50%.2 Purpose This study aimed to assess the clinical and prognostic relevance of longitudinal changes in ePCWP over time among HF patients with LVEF 50%. Methods A total of 254 HF outpatients (mean age 71±12 years, 76% male, 35% with atrial fibrillation, baseline LVEF 34±9%, baseline ePCWP 16±5 mmHg) who underwent two echocardiographic assesments 12±3 months apart were included. Patients were classified into three groups based on ePCWP changes at the second echocardiographic study: increased (n=22, 9%), decreased (n=54, 21%), or stable (ePCWP ≤15 mmHg n=89, 35% or 15 mmHg n=87, 34% at both assessments). The primary endpoint was a composite of cardiac death or HF hospitalization. Results Patients with increased ePCWP exhibited worse NYHA class, more pronounced adverse cardiac remodelling, greater systolic-diastolic dysfunction, and higher neurohormonal activation compared to those with decreased or stable ePCWP (all p0.05). No significant association was observed between ePCWP changes and HF therapy optimization (including diuretic therapy), although a slight worsening of ePCWP was noted in those with ACEi/ARNI and MRA downtitration (p0.05). Over a median follow-up of 57 (34-72) months, changes in ePCWP stratified patients according to their risk of the primary endpoint (Log-Rank 42, p0.001). A 3-mmHg increase in ePCWP retained prognostic significance in the overall cohort (p0.001) and among patients with persistently elevated ePCWP at both time points (p=0.022). At adjusted regression analysis, both baseline ePCWP values and an increase 3 mmHg over time resulted independent predictors of the primary endpoint (p=0.016 and p=0.024, respectively). A predictive model including basal ePCWP and its longitudinal increase over 3 mmHg outperformed LVEF, natriuretic peptides, and current diastolic dysfunction grading reassessments over time in outcome prediction (p0.001). Conclusion Longitudinal changes in ePCWP provide incremental clinical and prognostic information beyond baseline values in a cohort of HF patients with LVEF 50%.Figure 1. Figure 2.