Current practice for determining pulmonary capillary wedge pressure predisposes to serious errors in the classification of patients with pulmonary hypertension

doi:10.1016/j.ahj.2012.01.024

American Heart Journal

Volume 163, Issue 4, April 2012, Pages 589-594

https://doi.org/10.1016/j.ahj.2012.01.024 Get rights and content

Background

Accurate measurement of left ventricular filling pressure is important to distinguish between category 1 pulmonary arterial hypertension (PAH) and category 2 pulmonary hypertension (PH) from left heart diseases (PH-HFpEF). We hypothesized that the common practice of relying on the digitized mean pulmonary capillary wedge pressure (PCWP-digital) results in erroneous recordings, whereas end-expiratory PCWP measurements (PCWP–end Exp) provide a reliable surrogate measurement for end-expiratory left ventricular end-diastolic pressure (LVEDP–end Exp–end Exp).

Methods

We prospectively performed left and right cardiac catheterization on 61 patients referred for evaluation of PH and compared the LVEDP–end Exp to end-expiration to the (a) PCWP–end Exp and (b) PCWP-digital.

Results

The PCWP–end Exp was a more reliable reflection of LVEDP–end Exp (mean 13.2 mm Hg vs 12.4 mm Hg; P, nonsignificant) than PCWP-digital (mean 8.0 mm Hg vs 12.4 mm Hg, P < .05). Bland-Altman analysis of PCWP-digital and LVEDP–end Exp revealed a mean bias of −4.4 mm Hg with 95% limits of agreement of −11.3 to 2.5 mm Hg. Bland-Altman analysis of PCWP–end Exp and LVEDP–end Exp revealed a mean bias of 0.9 mm Hg with 95% limits of agreement of −5.2 to 6.9 mm Hg. If PCWP-digital were used to define LVEDP–end Exp, 14 (27%) of 52 patients would have been misclassified as having PAH rather than PH-HFpEF. Patients with obesity and hypoxia were particularly more likely to be misclassified as PAH instead of PH-HFpEF if PCWP-digital was used to define LVEDP–end Exp (odds ratio 8.1, 95% CI 1.644-40.04, P = .01).

Conclusions

The common practice of using PCWP-digital instead of PCWP–end Exp results in a significant underestimation of LVEDP–end Exp. In our study, this translated to nearly 30% of patients being misclassified as having PAH rather than PH from HFpEF.

Section snippets

Methods

This study was approved by the institutional review board from the University of Chicago Medical Center, and all patients gave informed consent. The patients in this study were all new referrals with a presumed diagnosis of PH who underwent their initial diagnostic right and left heart catheterization at the University of Chicago Medical Center from October 2006 to February 2011. At the time of catheterization, the pressure transducers were adjusted to reflect the midthorax in each patient

Baseline characteristics

The baseline characteristics of the patients in this study are shown in Table I. There were 61 patients with a mean age of 57 ± 14 years, and 79% were female. The average mean PAP was 42 ± 14 mm Hg, and the average PVR was 6.96 ± 4.88 Woods Units, consistent with moderate-severe PH.

Hemodynamic parameters

Among the cohort of patients referred for possible PH, 85% (n = 52) had markedly elevated PAP confirmed during cardiac catheterization. Among those, 69% (n = 36) were categorized as having PAH as determined by the

Discussion

This study confirms the observation by Forrester et al⁵ and underscores our concern about the misclassification of patients with PH as having PAH rather than PH-HFpEF if the PCWP-digital is used instead of the PCWP–end Exp or the LVEDP–end Exp. The PCWP-digital measurement misclassified nearly 30% of the patients referred with suspected PH for diagnosis. In fact, in our cohort, using the PCWP-digital measurement instead of the PCWP–end Exp or the LVEDP–end Exp would have classified 87.5% (n =

Conclusions

The common practice of using PCWP-digital measurements instead of PCWP–end Exp measurements during cardiac catheterization results in a significant underestimation of the LVEDP–end Exp. In our study, this translated to almost 30% of patients with PH being misclassified as having PAH rather than PH-HFpEF. When using the PCWP as a surrogate measurement for the LVEDP–end Exp, physicians need to ensure that only the PCWP at end-expiration be reported, especially in those with hypoxic lung disease

Disclosures

There are no conflicts of interest.

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Citation Excerpt :
In 1 substantial study from Vanderpool and colleagues,4 the prevalence of CpC PH by transpulmonary gradient (TPG) (>12 mm Hg), pulmonary vascular resistance (PVR) (>3 Woods units), and diastolic pulmonary gradient (DPG) (≥7 mm Hg) criteria were 46%, 36%, and 12% respectively, in PH from LH disease. This study and most others, however, have relied on automated pressures averaged throughout respiration, which underestimates true intravascular pressure due to varying effects of pleural pressure on measured intrathoracic pressures, as opposed to the correct assessment at end expiration when pleural pressure equals atmospheric pressure.24,25 In the same study,4 a substantial number of patients had negative DPG gradients between the PA and PCWP, which is a physiologic impossibility at the near-zero flow state at end diastole.
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Pulmonary hypertension (PH) is a heterogeneous, severe and progressive disease with an impact on quality of life and life-expectancy despite specific therapies.
(i) to compare prognosis significance of each PH subgroup in a cohort from a referral center, (ii) to identify phenotypically distinct high-risk PH patient using machine learning.
Patients with PH were included from 2002 to 2019 and routinely followed-up. We collected clinical, laboratory, imaging and hemodynamic variables. Four-year survival rate of each subgroups was then compared. Next, phenotypic domains were imputed with 5 eigenvectors for missing values and filtered if the Pearson correlation coefficient was > 0.6. Thereafter, agglomerative hierarchical clustering was used for grouping phenotypic variables and patients: a heat map was generated and participants were separated using Penalized Model-Based Clustering. P < 0.05 was considered significant.
328 patients were prospectively included (mean age 63 ± 18 yo, 46% male). PH secondary to left heart disease (PH-LHD) and lung disease (PH-LD) had a significantly increased mortality compared to pulmonary arterial hypertension (PAH) patients: HR = 2.43, 95%CI = (1.24–4.73) and 2.95, 95%CI = (1.43–6.07) respectively. 25 phenotypic domains were pinpointed and 3 phenogroups identified. Phenogroup 3 had a significantly increased mortality (log-rank P = 0.046) compared to the others and was remarkable for predominant pulmonary disease in older male, accumulating cardiovascular risk factors, and simultaneous three major comorbidities: coronary artery disease, chronic kidney disease and interstitial lung disease.
PH-LHD and PH-LD has 2-fold and 3-fold increase in mortality, respectively compared with PAH. PH patients with simultaneous kidney-cardiac-pulmonary comorbidities were identified as having high-risk of mortality. Specific targeted therapy in this phenogroup should be prospectively evaluated.
L’hypertension pulmonaire (HTP) est une pathologie hétérogène, sévère et chronique avec un impact sur la qualité et l’espérance de vie malgré l’arrivée de plusieurs thérapeutiques spécifiques.
Comparer le pronostic des 5 formes d’HTP entre elles à partir d’une cohorte d’un centre de compétence, et identifier, à l’aide du machine learning, un phénotype de patient au pronostic péjoratif.
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Clinical InvestigationCongestive Heart FailureCurrent practice for determining pulmonary capillary wedge pressure predisposes to serious errors in the classification of patients with pulmonary hypertension

Background

Methods

Results

Conclusions

Section snippets

Methods

Baseline characteristics

Hemodynamic parameters

Discussion

Conclusions

Disclosures

Am Heart J

Am Heart J

Chest

Am Heart J

Chest

Chest

Chest

Chest

J Crit Care

Clinical Investigation
Congestive Heart Failure
Current practice for determining pulmonary capillary wedge pressure predisposes to serious errors in the classification of patients with pulmonary hypertension