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

64 Journal of Cardiac Failure Vol. 20 No. 1 January 2014 recently. Most of those studies did not compare simultaneous measurements of pulmonary arterial pressure (PAP) by Doppler echocardiography obtained during right heart catheterization (RHC), so fluctuations in PAP at different points in time may have affected their findings. Recently, Nagueh et al (using the same method as in our study) reported that echocardiographic pulmonary artery systolic pressure (PASP) determinations correlate well (r 5 0.83) with invasive estimates in acute HF, with a mean difference of 3 6 3.6 mm Hg.2 Importantly, echocardiography identified patients with elevated invasive systolic pulmonary arterial pressure (defined as O35 mm Hg) with 94% sensitivity and 90% specificity. Thus, echocardiography may misclassify a small number of patients regarding the diagnosis of pulmonary hypertension, as may occur in any clinical test. In patients with pulmonary arterial hypertension, the imprecision of Doppler echocardiography estimates of PASP compared with catheter-based estimates may lead to subsequent inappropriate diagnoses and management decisions regarding the use of expensive therapies or the response to pulmonary vasodilators.3 However, in patients with acute decompensated heart failure (ADHF), RHC is not required for diagnosis and, following the results of the ESCAPE trial,4 RHC is used infrequently to guide therapy. Currently, in patients with heart failure, RHC is the gold standard for the evaluation of stage D heart failure patients and before considering pulmonary hypertensionespecific therapies.5 In patients with ADHF, the extent of the imprecision of Doppler echocardiography estimates of PASP compared with catheter-based estimates is unlikely to lead to erroneous clinical decisions. However, echocardiographic estimation of PASP captures the severity of the hemodynamic derangements, and can potentially indicate the presence of a reactive pulmonary vascular component. Importantly, the clinical validity of PASP estimates in heart failure is supported by its robust prognostic significance. Ample data from patients with heart failure indicate that elevated PASP is associated with increased mortality risk,5e9 and that this risk is modulated by right ventricular function.1,8,10 Thus there is overwhelming evidence that pulmonary hypertension and right ventricular function provide independent prognostic information in heart failure.

Disclosures None.

Doron Aronson, MD Robert Dragu, MD Department of Cardiology, Rambam Medical Center Haifa, Israel Zaher S. Azzam, MD Department of Internal Medicine B Ruth & Bruce Rappaport Faculty of Medicine Technion, Israel Institute of Technology Haifa, Israel

References 1. Aronson D, Darawsha W, Atamna A, Kaplan M, Makhoul BF, Mutlak D, et al. Pulmonary hypertension, right ventricular function, and clinical outcome in acute decompensated heart failure. J Card Fail 2013;19:665e71. 2. Nagueh SF, Bhatt R, Vivo RP, Krim SR, Sarvari SI, Russell K, et al. Echocardiographic evaluation of hemodynamics in patients with decompensated systolic heart failure. Circ Cardiovasc Imaging 2011;4:220e7. 3. Rich JD, Shah SJ, Swamy RS, Kamp A, Rich S. Inaccuracy of Doppler echocardiographic estimates of pulmonary artery pressures in patients with pulmonary hypertension: implications for clinical practice. Chest 2011;139:988e93. 4. Binanay C, Califf RM, Hasselblad V, O’Connor CM, Shah MR, Sopko G, et al. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA 2005;294:1625e33. 5. Kalogeropoulos AP, Georgiopoulou VV, Borlaug BA, Gheorghiade M, Butler J. Left ventricular dysfunction with pulmonary hypertension: part 2: prognosis, noninvasive evaluation, treatment, and future research. Circ Heart Fail 2013;6:584e93. 6. Lam CS, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, Redfield MM. Pulmonary hypertension in heart failure with preserved ejection fraction: a community-based study. J Am Coll Cardiol 2009; 53:1119e26. 7. Damy T, Goode KM, Kallvikbacka-Bennett A, Lewinter C, Hobkirk J, Nikitin NP, et al. Determinants and prognostic value of pulmonary arterial pressure in patients with chronic heart failure. Eur Heart J 2010;31:2280e90. 8. Ghio S, Temporelli PL, Klersy C, Simioniuc A, Girardi B, Scelsi L, et al. Prognostic relevance of a noninvasive evaluation of right ventricular function and pulmonary artery pressure in patients with chronic heart failure. Eur J Heart Fail 2013;15:408e14. 9. Aronson D, Eitan A, Dragu R, Burger AJ. Relationship between reactive pulmonary hypertension and mortality in patients with acute decompensated heart failure. Circ Heart Fail 2011;4:644e50. 10. Ghio S, Gavazzi A, Campana C, Inserra C, Klersy C, Sebastiani R, et al. Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure. J Am Coll Cardiol 2001;37:183e8. http://dx.doi.org/10.1016/j.cardfail.2013.11.009

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