Mild Elevation of Pulmonary Arterial Pressure as a Predictor of Mortality
Mild Elevation of Pulmonary Arterial Pressure as a Predictor of Mortality
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DOI：
10.1164/rccm.201706-1215oc
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发表时间：
2018-02-15
影响因子：
24.7
通讯作者：
Olschewski, Horst
中科院分区：
文献类型：
--
作者：
Douschan, Philipp;Kovacs, Gabor;Olschewski, Horst
依据：正常平均肺动脉压（mPAP）为14.0 +/- 3.3 mm Hg（平均值+/- SD）。不符合肺动脉高压定义的mPAP轻度升高的预后相关性（PH; mPAP >= 25 mm Hg）尚未在现实环境中进行前瞻性评估。目的：评估静息mPAP与不明原因呼吸困难和/或PH风险患者的回顾性和前瞻性队列中全因死亡率的相关性。方法：通过1）分类和回归树（CART）分析（无任何预设阈值）和2）基于文献数据的预设阈值（将mPAP定义为正常下限（= 25 mm Hg））计算预后临界值。我们进行了单变量和多变量生存分析调整年龄和comorbidity.Measurements和主要结果：我们招募了547例患者，其中137，56，64，和290低于正常，高于正常，或临界mPAP，和明显的PH，分别。对mPAP的CART分析区分了三个预后组：mPAP小于17 mm Hg、17 - 26 mm Hg和大于26 mm Hg，生存率显著降低。基于预设阈值的单变量分析显示，与正常mPAP较低相比，正常mPAP较高、临界mPAP和明显PH与生存不良显著相关。在多变量模型中，考虑到年龄和合并症，只有临界mPAP（风险比，2.37; 95%置信区间，1.14-4.97; P = 0.022）和显性PH（风险比，5.05; 95%可信区间，2.79-9.12; P < 0.001）与生存率差显著相关。在有PH风险和/或不明原因呼吸困难的患者中，CART分析检测静息mPAP为17 mm Hg和26 mm Hg的预后阈值，20 mm Hg和25 mm Hg之间的值代表生存不良的独立预测因子。
Rationale: Normal mean pulmonary arterial pressure (mPAP) is 14.0 +/- 3.3 mm Hg (mean +/- SD). The prognostic relevance of mildly elevated mPAP not fulfilling the definition of pulmonary hypertension (PH; mPAP >= 25 mm Hg) has not been prospectively evaluated in a real-world setting.Objectives: To assess the association of resting mPAPwith all-cause mortality in a retrospective and a prospective cohort of patients with unexplained dyspnea and/or at risk of PH.Methods: Prognostic cutoffs were calculated by means of 1) classification and regression tree (CART) analysis without any preset thresholds, and 2) preset thresholds on the basis of literature data defining mPAP as lower-normal (= 25 mm Hg). We performed univariate and multivariate survival analysis adjusted for age and comorbidities.Measurements and Main Results: We enrolled 547 patients, of whom 137, 56, 64, and 290 presented with lower-normal, upper-normal, or borderline mPAP, and manifest PH, respectively. The CART analysis on mPAP discriminated three prognostic groups: mPAP less than 17 mm Hg, 17 to 26 mm Hg, and greater than 26 mm Hg, with significantly decreasing survival. The univariate analysis on the basis of preset thresholds showed that upper-normal mPAP, borderline mPAP, and manifest PH were significantly associated with poor survival compared with lower-normal mPAP. In the multivariate model, considering age and comorbidities, only borderline mPAP (hazard ratio, 2.37; 95% confidence interval, 1.14-4.97; P = 0.022) and manifest PH (hazard ratio, 5.05; 95% confidence interval, 2.79-9.12; P < 0.001) were significantly associated with poor survival.Conclusions: In patients at risk for PH and/or with unexplained dyspnea, CART analysis detects prognostic thresholds at a resting mPAP of 17 mm Hg and 26 mm Hg, and values between 20mm Hg and 25mm Hg represent an independent predictor of poor survival.