Pulmonary Hypertension with Left Heart Disease: Prevalence, Temporal Shifts in Etiologies and Outcome

Tatyana Weitsman; Giora Weisz; Rivka Farkash; Marc Klutstein; Adi Butnaru; David Rosenmann; Tal Hasin

doi:10.1016/j.amjmed.2017.05.003

Pulmonary Hypertension with Left Heart Disease: Prevalence, Temporal Shifts in Etiologies and Outcome

Am J Med. 2017 Nov;130(11):1272-1279. doi: 10.1016/j.amjmed.2017.05.003. Epub 2017 May 26.

Authors

Tatyana Weitsman¹, Giora Weisz¹, Rivka Farkash¹, Marc Klutstein¹, Adi Butnaru¹, David Rosenmann¹, Tal Hasin²

Affiliations

¹ Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel.
² Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel. Electronic address: hasint@szmc.org.il.

PMID: 28552430
DOI: 10.1016/j.amjmed.2017.05.003

Abstract

Introduction: Pulmonary hypertension has many causes. While it is conventionally thought that the most prevalent is left heart disease, little information about its proportion, causes, and implications on outcome is available.

Methods: Between 1993 and 2015, 12,115 of 66,949 (18%) first adult transthoracic echocardiograms were found to have tricuspid incompetence gradient ≥40 mm Hg, a pulmonary hypertension surrogate. Left heart disease was identified in 8306 (69%) and included valve malfunction in 4115 (49%), left ventricular systolic dysfunction in 2557 (31%), and diastolic dysfunction in 1776 (21%). Patients with left heart disease, as compared with those without left heart disease, were of similar age, fewer were females (50% vs 63% P <.0001), and they had higher tricuspid incompetence gradient (median 48 mm Hg [interquartile range 43, 55] vs 46 mm Hg [42, 54] P <.0001). In reviewing trends over 20 years, the relative proportions of systolic dysfunction decreased and diastolic dysfunction increased (P for trend <.001), while valve malfunction remained the most prevalent cause of pulmonary hypertension with left heart disease. Independent predictors of mortality were age (hazard ratio [HR] 1.05; 95% CI, 1.04-1.05; P <.0001), tricuspid incompetence gradient (HR 1.02; 95% CI, 1.01-1.02, P <.0001 per mm Hg increase), and female sex (HR 0.87; 95% CI, 0.83-0.91, P <.0001).

Results: Overall, left heart disease was not an independent risk factor for mortality (HR 1.04; 95% CI, 0.99-1.09; P = .110), but patients with left ventricular systolic dysfunction and with combined systolic dysfunction and valve malfunction had increased mortality compared with patients with pulmonary hypertension but without left heart disease (HR 1.30; 95% CI, 1.20-1.42 and HR 1.44; 95% CI, 1.33-1.55, respectively; P <.0001 for both).

Conclusions: Pulmonary hypertension was found to be associated with left heart disease in 69% of patients. Among these patients, valve malfunction and diastolic dysfunction emerged as prominent causes. Left ventricular dysfunction carries additional risk to patients with pulmonary hypertension.

Keywords: Diastolic dysfunction; Heart valve disease; Survival; Systolic dysfunction; Tricuspid incompetence gradient.

MeSH terms

Aged
Aged, 80 and over
Echocardiography* / methods
Echocardiography* / statistics & numerical data
Female
Hemodynamics
Humans
Hypertension, Pulmonary* / diagnosis
Hypertension, Pulmonary* / etiology
Hypertension, Pulmonary* / mortality
Hypertension, Pulmonary* / physiopathology
Israel / epidemiology
Male
Middle Aged
Mortality
Outcome Assessment, Health Care
Prevalence
Retrospective Studies
Risk Assessment / methods
Risk Factors
Tricuspid Valve Insufficiency* / diagnosis
Tricuspid Valve Insufficiency* / physiopathology
Ventricular Dysfunction, Left* / complications
Ventricular Dysfunction, Left* / diagnosis
Ventricular Dysfunction, Left* / epidemiology
Ventricular Dysfunction, Left* / physiopathology