Misclassification of Pulmonary Hypertension Due to Reliance on Pulmonary Capillary Wedge Pressure Rather Than Left Ventricular End-Diastolic Pressure

doi:10.1378/chest.08-2784

Chest

Volume 136, Issue 1, July 2009, Pages 37-43

https://doi.org/10.1378/chest.08-2784 Get rights and content

Background

Pulmonary arterial hypertension (PAH) is typically distinguished from pulmonary venous hypertension (PVH) by documenting a pulmonary capillary wedge pressure (PCWP) ≤ 15 mm Hg. However, PCWP has uncertain utility in establishing PAH. We sought to determine the calibration, discrimination, and diagnostic accuracy of PCWP, using simultaneously measured left ventricular end-diastolic pressure (LVEDP) as the “gold standard.”

Methods

We examined hemodynamic data from the 11,523 unique patients undergoing simultaneous right-heart and left-heart catheterization at a large academic center from 1998 to 2007.

Results

Among 4,320 patients (37.5%) with pulmonary hypertension (PH) [mean pulmonary artery pressure, ≥ 25 mm Hg], hemodynamic data were complete for 3,926 patients (90.9%). Of these, 580 patients (14.8%) met the criteria for PAH with a PCWP ≤ 15 mm Hg, but 310 of these patients (53.5%) had an LVEDP > 15 mm Hg. Such discrepancies remained common among patients with a pulmonary vascular resistance > 3 Wood units and those being catheterized specifically to evaluate PH. PCWP provided moderate discrimination between patients with high vs normal LVEDP (area under the receiver operating characteristic curve, 0.84; 95% confidence interval, 0.81 to 0.86) but was poorly calibrated to LVEDP (Bland-Altman limits of agreement, − 15.2 to 9.5 mm Hg; Hosmer-Lemeshow goodness-of-fit χ² statistic, 155.4; p < 0.0001).

Conclusions

Roughly half of the patients presumed to have PAH based on PCWP may be found to have PVH based on LVEDP. Reliance on PCWP may result in the dangerous or cost-ineffective use of pulmonary vasodilators for patients with left-heart disease. Furthermore, without assessing LVEDP, investigators may include patients with left-heart disease in therapeutic trials of PAH drugs, thereby limiting their ability to detect beneficial drug effects.

Section snippets

Patients

All patients undergoing right-heart catheterization at Penn-Presbyterian Medical Center, a large, community-based, academic hospital and regional referral center for pulmonary vascular disease affiliated with the University of Pennsylvania Health System, from January 1, 1998, to December 31, 2007, were included in the study. This study was deemed exempt from review by the University of Pennsylvania Institutional Review Board because it used previously collected, deidentified data.

Patients were

Results

There were 12,744 eligible unique patients who underwent right-heart catheterization at our institution from 1998 to 2007. Of these, 11,523 patients underwent combined catheterizations, and 4,320 patients (37.5%) had PH (Fig 1).

Discussion

This study of a large number of patients undergoing sequential measurement of PCWP and LVEDP suggests that PCWP frequently underestimates LVEDP, that it is poorly calibrated to LVEDP, and that it has a moderate ability to discriminate between patients with normal or elevated LVEDP. Perhaps most importantly, these results suggest that approximately half of all patients who meet the hemodynamic criteria for PAH on the basis of PCWP measurements may, in fact, have elevated left ventricular filling

Conclusions

Some might conclude from our results that LVEDP should be measured routinely among all patients referred for catheterization as part of an evaluation for PH. However, this approach carries increased risks and inconveniences for patients as well as increased costs and resource utilization. We therefore suggest a more conservative approach in routine practice in which clinicians obtain left-heart hemodynamic measurements whenever there are reasons to suspect left-heart disease based on the

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Cited by (201)

Lung ultrasonography derived B-line scores as predictors of left ventricular end-diastolic pressure and pulmonary artery wedge pressure
2023, Respiratory Medicine
Non-invasive assessment of elevated left ventricular end-diastolic pressure (LVEDP) and pulmonary artery wedge pressure (PAWP) in patients with heart diseases is challenging. Lung ultrasonography (LUS) is a promising modality for predicting LVEDP and PAWP.
Fifty-seven stable ambulatory patients who underwent right and left heart catheterization were included. Following the procedures, LUS was performed in twenty-eight ultrasonographic zones, and the correlation between five different LUS derived B-line scores with LVEDP and PAWP was examined.
The B-line index correlated with LVEDP and PAWP, with coefficients of 0.45 (p = 0.006) and 0.30 (p = 0.03), respectively. B-line index showed an AUC of 0.76 for identifying LVEDP > 15 mmHg (p = 0.01) and an AUC of 0.73 for identifying PAWP > 15 mmHg (p = 0.008). Overall, scores performances were similar in predicting LVEDP or PAWP > 15 mmHg. A B-line index ≥ 28 was significantly associated with LVEDP > 15 mmHg (OR: 9.97) and PAWP > 15 mmHg (OR: 6.61), adjusted for age and indication for heart catheterization.
LUS derived B-line scores are moderately correlated with PAWP and LVEDP in patients with heart diseases. A B-line index ≥ 28 can be used to predict elevated LVEDP and PAWP with high specificity.
Reply: About Left Ventricular Filling Pressures in CTEPH
2023, Journal of the American College of Cardiology
Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study
2023, Revista Espanola de Cardiologia
El remodelado vascular pulmonar es prevalente en la insuficiencia cardiaca avanzada. El cateterismo derecho es la prueba de elección, pero está limitado por la asunción de medidas indirectas, un enfoque de flujo no pulsátil, su dependencia de la carga o la variabilidad en la interpretación. Nuestro objetivo es evaluar la vasculopatía pulmonar mediante tomografía de coherencia óptica (OCT) intravascular y correlacionarla con los parámetros hemodinámicos.
Estudio observacional, prospectivo y multicéntrico que incluyó a 100 pacientes en estudio previo al trasplante cardiaco. Todos se sometieron a un cateterismo derecho con OCT de la arteria pulmonar.
La OCT se pudo analizar en 90 casos. La mediana de edad fue 57,50 [intervalo intercuartílico, 48,75-63,25] años y 71 eran varones (78,88%). La cardiopatía subyacente más frecuente fue la miocardiopatía dilatada no isquémica (33 pacientes [36,66%]). El grosor intimal se correlacionó con la presión arterial pulmonar media, las resistencias vasculares y el gradiente transpulmonar (coeficiente R de 0,42, 0,27 y 0,32 respectivamente). La estimación no invasiva de la presión sistólica pulmonar, el tiempo de aceleración y el acoplamiento ventriculoarterial también se correlacionaron con el grosor intimal (coeficiente R de 0,42, 0,27 y 0,49 respectivamente). Los pacientes con un grosor intimal > 0,25 mm presentaron mayores presión pulmonar media (37,00 frente a 25,00 mmHg; p = 0,004) y resistencias vasculares (3,44 frente a 2,08 UW; p = 0,017).
La OCT pulmonar es factible y está significativamente asociada con los datos hemodinámicos. La correlación débil indica que el remodelado vascular no explica por completo la hipertensión pulmonar.
Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data.
This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery.
OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient = 0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25 mm had significantly higher mean pulmonary pressures (37.00 vs 25.00 mmHg; P = .004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P = .017).
Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.
Wedge Pressure vs Left Ventricular End-Diastolic Pressure for Pulmonary Hypertension Classification and Prognostication in Severe Aortic Stenosis
2021, CJC Open
Differentiation between precapillary and postcapillary pulmonary hypertension (PH) classically relies on mean pulmonary artery wedge pressure (mPAWP). The left ventricular end-diastolic pressure (LVEDP) is proposed as an equivalent alternative. However, mPAWP and LVEDP may differ substantially. We compared the impact of the choice of using the mPAWP vs the LVEDP on PH classification and mortality prediction in patients with severe aortic stenosis (AS) undergoing valve replacement.
In 335 patients with severe AS , both mPAWP and LVEDP were measured. A mean pulmonary artery pressure ≥ 25 mm Hg was used to define PH, and either mPAWP or LVEDP was used to differentiate between precapillary and postcapillary PH (≤ 15 vs > 15 mm Hg). Mortality after a median follow-up of 1484 days after aortic valve replacement was assessed.
Overall, mPAWP was lower than LVEDP (16 ± 8 mm Hg vs 21 ± 8 mm Hg; P < 0.001). Among 140 patients (42%) with PH, the PAWP-based classification revealed 76 (54% of those with PH) with isolated postcapillary PH, 48 (34%) with combined pre- and postcapillary PH, and 16 (12%) with precapillary PH. When the LVEDP was used, 59 patients (42%) were differently classified. These patients had higher mortality than those who were not differently classified [hazard ratio 2.79 (95% confidence interval, 1.17-6.65); P = 0.02]. Higher mPAWP was associated with increased mortality [hazard ratio 1.07 (95% confidence interval, 1.03-1.11) per 1 mm Hg; P = 0.001], whereas higher LVEDP was not.
Use of LVEDP rather than mPAWP results in a divergent PH classification in nearly every second patient with severe AS. These patients have higher mortality after aortic valve replacement. The mPAWP, but not the LVEDP, predicts mortality.
La différentiation entre l’hypertension pulmonaire (HP) précapillaire et postcapillaire repose traditionnellement sur la pression artérielle pulmonaire d’occlusion moyenne (PAPOm). La pression télédiastolique du ventricule gauche (PTDVG) est proposée comme alternative équivalente. Toutefois, la PAPOm et la PTDVG peuvent largement différer. Nous avons comparé les répercussions du choix entre l’utilisation de la PAPOm vs l’utilisation de la PTDVG sur la classification de l’HP et la prédiction de la mortalité des patients atteints d’une sténose aortique (SA) grave qui subissaient un remplacement valvulaire.
Nous avons mesuré la PAPOm et la PTDVG de 335 patients atteints de SA grave. Nous avons utilisé une pression artérielle pulmonaire moyenne ≥ 25 mmHg pour définir l’HP, et utilisé la PAPOm ou la PTVDG pour différencier entre l’HP précapillaire et postcapillaire (≤ 15 mmHg vs > 15 mmHg). Nous avons évalué la mortalité après un suivi médian de 1 484 jours après le remplacement valvulaire aortique.
Dans l’ensemble, la PAPOm était plus faible que la PTVDG (16 ± 8 mmHg vs 21 ±8 mmHg; P < 0,001). Parmi les 140 patients (42 %) atteints d’HP, la classification en fonction de la PAPO a révélé 76 (54 % des patients atteints d’HP) patients atteints d’HP postcapillaire isolée, 48 (34 %) patients atteints d’HP précapillaire et postcapillaire combinée et 16 (12 %) patients atteints d’HP précapillaire. Lorsque nous avons utilisé la PTVDG, 59 patients (42 %) étaient classifiés différemment. La mortalité chez ces patients était plus élevée que chez les patients qui n’étaient pas classifiés différemment (rapport de risque 2,79 [intervalle de confiance à 95 %, 1,17-6,65]; P = 0,02). La PAPOm plus élevée était associée à une mortalité accrue (rapport de risque 1,07 [intervalle de confiance à 95 %, 1,03-1,11] par 1 mmHg; P = 0,001), tandis que la PTVDG plus élevée ne l’était pas.
Le fait d’utiliser la PTVDG plutôt que la PAPOm entraîne une classification divergente de l’HP chez presque tous les deux patients atteints de SA grave. La mortalité après le remplacement valvulaire aortique de ces patients est plus élevée. La PAPOm, mais non la PTVDG, prédit la mortalité.
Harnessing Artificial Intelligence for Quantitative Assessment of Hemodynamic Congestion and Predicting Outcomes
2021, JACC: Cardiovascular Imaging
Tissue Doppler Imaging (E/e’) and Pulmonary Capillary Wedge Pressure in Patients With Severe Aortic Stenosis
2021, Journal of Cardiothoracic and Vascular Anesthesia
Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e’) in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e’ and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis.
Retrospective cohort study.
The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis.
None.
PCWP and E/e’_ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF <50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e’_ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF <50%: n = 11, Spearman r = –0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e’_ave.
A clinically relevant relationship between E/e’ and PCWP was not observed in patients with severe aortic stenosis.

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This work was supported by an American Thoracic Society Fellows Career Development Award (Dr. Halpern).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

¹: Drs. Halpern and Taichman have each received support from Actelion Pharmaceuticals to conduct other research related to pulmonary hypertension. The authors have no other involvement with organizations with a financial interest in the subject matter of this article.

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Chest

Original ResearchPulmonary HypertensionMisclassification of Pulmonary Hypertension Due to Reliance on Pulmonary Capillary Wedge Pressure Rather Than Left Ventricular End-Diastolic Pressure

Background

Methods

Results

Conclusions

Section snippets

Patients

Results

Discussion

Conclusions

Chest

Clin Chest Med

Chest

Clin Chest Med

Chest

Ann Thorac Surg

Lancet

Guidelines on diagnosis and treatment of pulmonary arterial hypertension: The Task Force on Diagnosis and Treatment of Pulmonary Arterial Hypertension of the European Society of Cardiology

Eur Heart J

Pulmonary hypertension out of proportion to left heart disease

Adv Pulm Hypertens

Diagnosis and differential assessment of pulmonary arterial hypertension

J Am Coll Cardiol

Pulmonary arterial hypertension

Circulation

A century of pulmonary hemodynamics

Am J Respir Crit Care Med

Original Research
Pulmonary Hypertension
Misclassification of Pulmonary Hypertension Due to Reliance on Pulmonary Capillary Wedge Pressure Rather Than Left Ventricular End-Diastolic Pressure