Invasive and non-invasive determinants of pulmonary hypertension in patients with chronic heart failure
Invasive and non-invasive determinants of pulmonary hypertension in patients with chronic heart failure
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DOI：
10.1016/s1053-2498(00)00084-x
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发表时间：
2000-05-01
影响因子：
8.9
通讯作者：
Cobelli, F
中科院分区：
文献类型：
--
作者：
Capomolla, S;Febo, O;Cobelli, F
背景：在慢性心力衰竭患者中，肺动脉高压是不良结局的重要预测指标。目的：探讨慢性心力衰竭患者肺动脉高压的血流动力学因素，并比较多普勒指标与有创血流动力学指标的预测价值。对259例慢性心力衰竭患者同时进行右心导管检查和经胸超声多普勒检查（射血分数24% +/- 7%），处于窦性心律并接受优化的药物治疗。有创测量收缩期肺动脉压（sPAP）、心脏指数跨肺动脉压梯度和肺楔压（PWP）。左房、左室收缩容积、左室舒张容积、舒张早期最大充盈速度与舒张晚期最大充盈速度之比应用超声多普勒定量分析二尖瓣血流E/A比值、减速时间（DT）、心房充盈分数（AFF）、前向肺静脉血流收缩分数（SFPvf）和二尖瓣返流。肺动脉高压患者左心房收缩和舒张功能障碍更严重，左心室舒张功能异常更多，血流动力学损害更严重。收缩期左心室指数、二尖瓣返流和sPAP之间的相关性通常较差。在有创和无创测量中，PWP（r = 0.89，p < 0.0001）和SFPvf（r =-0.68，p < 0.0001）与sPAP的相关性最强。当我们将所有患者与无二尖瓣返流的患者进行比较时，E/A比值（r = 0.56 vs r = 0.74，p < 0.002）、SFPvf（r = -0.68 vs r =-0.84，p < 0.03）和收缩期肺动脉压之间的相关性显著更强。多变量分析显示，PWP是肺动脉收缩压最强的有创独立预测因子，（R-2 = 0.87，p < 0.0001）和无（R-2 = 0.90，p < 0.0001）二尖瓣返流，A PWP ≥ 18 mm Hg（比值比[95%CL]，142（41-570））与收缩期肺动脉高压密切相关。在非侵入性变量中，DT、SFPvf和AFF被确定为有二尖瓣返流（R-2 = 0.56，p < 0.0001）和无二尖瓣返流（R-2 = 0.78，p < 0.0001）患者sPAP的独立预测因子。A DT < 130（比值比[95% CLI，3.5（1.3-8.5），SFfvp < 40%（比值比[95%CL]，333（41- 1，007），AFF < 30%）（比值比[95%CL]，2（1.3-7）最强预测收缩期肺动脉高压。本研究结果表明，在慢性心力衰竭患者中，静脉肺充血是收缩期肺动脉高压的重要决定因素。血流动力学和多普勒决定因素在识别收缩期肺动脉高压方面显示出相似的预测能力。
Background: In patients with chronic heart failure, pulmonary hypertension is an important predictive marker of adverse outcome. Its invasive and non-invasive determinants have not been evaluated.Objective: This study was performed to evaluate hemodynamic determinants of pulmonary hypertension in chronic heart failure and to compare the predictive value of Doppler indices with that of invasively measured hemodynamic indices.Methods: Right heart catheterization and transthoracic echo-Doppler were simultaneously performed in 259 consecutive patients with chronic heart failure (ejection fraction 24% +/- 7%) who were in sinus rhythm and receiving optimized medical therapy. Systolic pulmonary artery pressure (sPAP), cardiac index transpulmonary gradient pressure, and pulmonary wedge pressure (PWP) were measured invasively. Left atrial and,ventricular systolic and diastolic volumes, the ratio of maximal early to late diastolic filling velocities (E/A ratio), deceleration time (DT) and atrial filling fraction (AFF) of transmitral flow, systolic fraction of forward pulmonary venous flow (SFpvf), and mitral regurgitation were quantified by echo-Doppler.Results: Patients with pulmonary hypertension had greater left atrial systolic and diastolic dysfunction, more left ventricular diastolic abnormalities, and greater hemodynamic impairment. The correlations between systolic left ventricular indices, mitral regurgitation, and sPAP were generally poor. Among invasive and non-invasive measurements, PWP (r = 0.89, p < 0.0001) and SFpvf (r = -0.68, p < 0.0001) showed the strongest correlation with sPAP. When we compared all patients with those without mitral regurgitation, the correlations between E/A ratio (r = 0.56 vs r = 0.74, p < 0.002), SFpvf (r = -0.68 vs r = -0.84, p < 0.03), and systolic pulmonary artery pressure were significantly stronger. Multivariate analysis revealed that PWP was the strongest invasive independent predictor of systolic pulmonary artery pressure in patients with (R-2 = 0.87, p < 0.0001) and without (R-2 = 0.90,p < 0.0001) mitral regurgitation, A PWP greater than or equal to 18 mm Hg (odds ratio [95% CL], 142 (41-570) was strongly associated with systolic pulmonary hypertension. Among non-invasive variables DT, SFpvf, and AFF were identified as independent predictors of sPAP in patients with (R-2 = 0.56, p < 0.0001) and without (R-2 = 0.78, p < 0.0001) mitral regurgitation. A DT < 130 (odds ratio [95% CLI, 3.5 (1.3-8.5), SFfvp < 40% (odds ratio [95% CL], 333 (41-1,007), and AFF < 30% (odds ratio [95% CL], 2 (1.3-7) most strongly predicted systolic pulmonary hypertension.Conclusions: The results of this study indicate that in patients with chronic heart failure, venous pulmonary congestion is an important determinant of systolic pulmonary artery hypertension. Hemodynamic and Doppler determinants showed similar predictive power in identifying systolic pulmonary artery hypertension.