Journal of Cardiac Failure Vol. 20 No. 1 2014
Letters to the Editor Disclosures
Acute Decompensated Heart Failure and Pulmonary Hypertension None.
Yavuzer Koza, MD Department of Cardiology Ataturk University Faculty of Medicine Erzurum, Turkey
To the Editor: I read with interest the article entitled “Pulmonary Hypertension, Right Ventricular Function, and Clinical Outcome in Acute Decompensated Heart Failure” by Aronson et al1 in a recent issue of Journal of Cardiac Failure. The authors reported that in patients with acute decompensated heart failure (ADHF), pulmonary hypertension (PH) and right ventricle function provide incremental prognostic information independently from other established predictors of outcome. I have some additional comments about that study. Systolic blood pressure measured at admission affects mortality during early follow-up and has a significant effect on outcome for at least 5 years.2 The definition of PH is not based solely on the sum of the peak systolic pressure gradient across the tricuspid valve and the right atrial pressure. It should be evaluated together with tricuspid regurgitation velocity and presence or absence of additional echocardiographic variables.3 It has been shown that pulmonary arterial pressure (PAP) estimation can be inaccurate with a range of 48%e54% and that PAP may be over- or underestimated from the tricuspid regurgitant velocity.4 Therefore, PH can not be reliably defined by a cutoff value of Doppler-derived PA systolic pressure. In heart failure (HF), chronic medical treatment is associated with demonstrable decreases in left ventricle (LV) size and improvement in LV function. Because patients with advanced chronic HF may have more fibrotic changes and patients with earlier stages of HF may have more reversibility, I wonder about the number of patients with new-onset ADHF in the present study. In another study, a history of HF was one of the strongest independent predictors of 5-year mortality in ADHF.5 Also, the authors did not give information about the treatment of patients (with, eg, inotropic agents, intravenous diuretics, and vasodilators) in the hospital course. Indeed, treatment of HF in acute settings may have some structural and functional effects that translate into the echocardiographic measurements. In an another study, Ramasubbu et al6 demonstrated that treatment of ADHF was significantly associated with decreasing in right atrium and right ventricle sizes and inferior vena cava dimensions. Consequently, it is hard to draw such a conclusion from this study as the one the authors suggested.
References 1. Aronson D, Darawsha W, Atamna A, Kaplan M, Makhoul BF, Mutlak D, et al. Pulmonary hypertension, right ventricular function, and clinicaloutcome in acute decompensated heart failure. J Card Fail 2013;19:665e71. 2. Siiril€a-Waris K, Lassus J, Melin J, Peuhkurinen K, Nieminen MS, Harjola VP. FINN-AKVA Study Group. Characteristics, outcomes, and predictors of 1-year mortality in patients hospitalized for acute heart failure. Eur Heart J 2006;27:3011e7. 3. Galie N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, et al. ESC Committee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009;30:2493e537. 4. Testani JM, St John Sutton MG, Wiegers SE, Khera AV, Shannon RP, Kirkpatrick JN. Accuracy of noninvasively determined pulmonary artery systolic pressure. Am J Cardiol 2010;15:1192e7. 5. Lassus JP, Siiril€a-Waris K, Nieminen MS, Tolonen J, Tarvasm€aki T, Peuhkurinen K, et al, FINN-AKVA Study Group. Long-term survival after hospitalization for acute heart failureddifferences in prognosis of acutely decompensated chronic and new-onset acute heart failure. Int J Cardiol 2013;168:458e62. 6. Ramasubbu K, Deswal A, Chan W, Aguilar D, Bozkurt B. Echocardiographic changes during treatment of acute decompensated heart failure: insights from the ESCAPE trial. J Card Fail 2012;18:792e8. http://dx.doi.org/10.1016/j.cardfail.2013.11.008
Reply to Acute Decompensated Heart Failure and Pulmonary Hypertension To the Editor: We greatly appreciate the comments of Dr. Koza regarding our article.1 Our study population included patients with established heart failure (only 5 were in New York Heart Association functional class I before admission), and the patients were generally hemodynamically stable (mean systolic blood pressure 135 6 27 mm Hg). The reliability of Doppler echocardiography to accurately estimate pulmonary pressures has been questioned 63
Letters to the Editor Disclosures
Acute Decompensated Heart Failure and Pulmonary Hypertension None.
Yavuzer Koza, MD Department of Cardiology Ataturk University Faculty of Medicine Erzurum, Turkey
To the Editor: I read with interest the article entitled “Pulmonary Hypertension, Right Ventricular Function, and Clinical Outcome in Acute Decompensated Heart Failure” by Aronson et al1 in a recent issue of Journal of Cardiac Failure. The authors reported that in patients with acute decompensated heart failure (ADHF), pulmonary hypertension (PH) and right ventricle function provide incremental prognostic information independently from other established predictors of outcome. I have some additional comments about that study. Systolic blood pressure measured at admission affects mortality during early follow-up and has a significant effect on outcome for at least 5 years.2 The definition of PH is not based solely on the sum of the peak systolic pressure gradient across the tricuspid valve and the right atrial pressure. It should be evaluated together with tricuspid regurgitation velocity and presence or absence of additional echocardiographic variables.3 It has been shown that pulmonary arterial pressure (PAP) estimation can be inaccurate with a range of 48%e54% and that PAP may be over- or underestimated from the tricuspid regurgitant velocity.4 Therefore, PH can not be reliably defined by a cutoff value of Doppler-derived PA systolic pressure. In heart failure (HF), chronic medical treatment is associated with demonstrable decreases in left ventricle (LV) size and improvement in LV function. Because patients with advanced chronic HF may have more fibrotic changes and patients with earlier stages of HF may have more reversibility, I wonder about the number of patients with new-onset ADHF in the present study. In another study, a history of HF was one of the strongest independent predictors of 5-year mortality in ADHF.5 Also, the authors did not give information about the treatment of patients (with, eg, inotropic agents, intravenous diuretics, and vasodilators) in the hospital course. Indeed, treatment of HF in acute settings may have some structural and functional effects that translate into the echocardiographic measurements. In an another study, Ramasubbu et al6 demonstrated that treatment of ADHF was significantly associated with decreasing in right atrium and right ventricle sizes and inferior vena cava dimensions. Consequently, it is hard to draw such a conclusion from this study as the one the authors suggested.
References 1. Aronson D, Darawsha W, Atamna A, Kaplan M, Makhoul BF, Mutlak D, et al. Pulmonary hypertension, right ventricular function, and clinicaloutcome in acute decompensated heart failure. J Card Fail 2013;19:665e71. 2. Siiril€a-Waris K, Lassus J, Melin J, Peuhkurinen K, Nieminen MS, Harjola VP. FINN-AKVA Study Group. Characteristics, outcomes, and predictors of 1-year mortality in patients hospitalized for acute heart failure. Eur Heart J 2006;27:3011e7. 3. Galie N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, et al. ESC Committee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009;30:2493e537. 4. Testani JM, St John Sutton MG, Wiegers SE, Khera AV, Shannon RP, Kirkpatrick JN. Accuracy of noninvasively determined pulmonary artery systolic pressure. Am J Cardiol 2010;15:1192e7. 5. Lassus JP, Siiril€a-Waris K, Nieminen MS, Tolonen J, Tarvasm€aki T, Peuhkurinen K, et al, FINN-AKVA Study Group. Long-term survival after hospitalization for acute heart failureddifferences in prognosis of acutely decompensated chronic and new-onset acute heart failure. Int J Cardiol 2013;168:458e62. 6. Ramasubbu K, Deswal A, Chan W, Aguilar D, Bozkurt B. Echocardiographic changes during treatment of acute decompensated heart failure: insights from the ESCAPE trial. J Card Fail 2012;18:792e8. http://dx.doi.org/10.1016/j.cardfail.2013.11.008
Reply to Acute Decompensated Heart Failure and Pulmonary Hypertension To the Editor: We greatly appreciate the comments of Dr. Koza regarding our article.1 Our study population included patients with established heart failure (only 5 were in New York Heart Association functional class I before admission), and the patients were generally hemodynamically stable (mean systolic blood pressure 135 6 27 mm Hg). The reliability of Doppler echocardiography to accurately estimate pulmonary pressures has been questioned 63
