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Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity.

ABSTRACT: The clinical relevance of non-invasively derived pulmonary arterial pressure (PAP) by Doppler echocardiography (DE) has been questioned in the past. However, transthoracic echocardiography is used as a cornerstone examination for patients with dyspnea and suspected pulmonary hypertension (PH). This study aimed to evaluate the prognostic value of non-invasive assessed PAP in a large population of patients with known or suspected cardiopulmonary disease.The analyses are based on data of patients of a tertiary cardiology center that received right heart catheterization (RHC) as well as non-invasively assessed PAP by DE within five days, and includes serological and clinical parameters in a retrospective follow-up for up to eight years.Of 1,237 patients, clinical follow-up was possible in 1,038 patients who were included in the statistical analysis. The mean-follow up time was 1,002 days. The composite endpoint of heart transplantation (HTx) or death occurred in n = 308 patients. Elevated PAP measured non-invasively as well as invasively had significant prognostic impact (hazard ratio (HR) 2.32; 95% confidence interval (CI) 1.78-3.04; ?2 = 37.9; p<0.001 versus HR 2.84; 95%CI 2.11-3.82; ?2 = 51.9; p<0.001, respectively). By multivariate analysis, NYHA functional class, N-terminal pro-brain natriuretic peptide, cardiac troponin T, left ventricular ejection fraction, and right ventricular dysfunction remained independently predictive. Incremental prognostic information in a multimodal approach was highly relevant.In this comprehensive study, elevated pulmonary arterial pressure measured by DE offers similar prognostic information on survival or need for HTx as right heart catheterization. Furthermore, the addition of functional capacity and serological biomarkers delivered incremental prognostic information.

SUBMITTER: Greiner S

PROVIDER: S-EPMC5774714 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity.

Greiner Sebastian S Jud Andreas A Aurich Matthias M Geisenberger Christoph C Uhlmann Lorenz L Hilbel Thomas T Kieser Meinhard M Katus Hugo A HA Mereles Derliz D

PloS one 20180119 1

<h4>Background</h4>The clinical relevance of non-invasively derived pulmonary arterial pressure (PAP) by Doppler echocardiography (DE) has been questioned in the past. However, transthoracic echocardiography is used as a cornerstone examination for patients with dyspnea and suspected pulmonary hypertension (PH). This study aimed to evaluate the prognostic value of non-invasive assessed PAP in a large population of patients with known or suspected cardiopulmonary disease.<h4>Methods</h4>The analy ...[more]

PMID: 29351312

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Project description:BackgroundWe aimed to evaluate associations of right atrial (RA) and right ventricular (RV) strain parameters assessed by 2D speckle tracking echocardiography (2D STE) with invasively measured hemodynamic parameters in patients with and without pulmonary hypertension (PH).MethodsIn this study, we analyzed 78 all-comer patients undergoing invasive hemodynamic assessment by left and right heart catheterization. Standard transthoracic echocardiographic assessment was performed under the same hemodynamic conditions. RA and RV longitudinal strain parameters were analyzed using 2D STE. PH was defined as invasively obtained mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest and was further divided into pre-capillary PH (pulmonary capillary wedge pressure [PCWP] ≤ 15 mmHg), post-capillary PH (PCWP > 15 mmHg) and combined PH (PCWP > 15 mmHg and difference between diastolic PAP and PCWP of ≥7 mmHg). Correlation analyses between variables were calculated with Pearson's or Spearman's correlation coefficient as applicable.ResultsOut of 78 patients, 45 presented with PH. Within the PH group, 39 had post-capillary, five had combined pre- and post-capillary PH, and one had pre-capillary PH. Patients with PH had a significantly increased RA area (PH 22.0 ± 9.2 cm2, non-PH 17.3 ± 10.7 cm2; p = 0.003) and end-systolic RV area (PH 14.7 ± 6.1, non-PH 11.9 ± 4.8 cm2; p = 0.022). RV mid strain was significantly reduced in PH (PH -17.4 ± 7.8, non-PH: - 21.6 ± 5.5; p = 0.019). Average peak systolic RA strain (RAS) and average peak systolic RV strain (RVS) showed a significant association with mPAP (r = - 0.470, p = 0.001 and r = 0.490, p = 0.001, respectively) and with PCWP (r = - 0.296, p = 0.048 and r = 0.365, p = 0.015, respectively) in patients with PH. Furthermore, RV apical, mid and basal strain as well as RV free wall strain showed moderate associations with mPAP. In patients without PH, there were no associations detectable between RA or RV strain parameters and mPAP and PCWP.ConclusionIn an all-comer cohort, RA and RV strain parameters showed significant associations with invasively assessed mPAP and PCWP in patients with predominantly post-capillary PH. These associations may be useful in clinical practice to assess the impact of post-capillary PH on myocardial right heart function.

Project description:BackgroundGlomerular hyperfiltration resulting from an elevated intraglomerular pressure (Pglom) is an important cause of CKD, but there is no feasible method to directly assess Pglom in humans. We developed a model to estimate Pglom in patients from combined renal arterial pressure and flow measurements.MethodsWe performed hemodynamic measurements in 34 patients undergoing renal or cardiac angiography under baseline conditions and during hyperemia induced by intrarenal dopamine infusion (30 μg/kg). For each participant during baseline and hyperemia, we fitted an adapted three-element Windkessel model that consisted of characteristic impedance, compliance, afferent resistance, and Pglom.ResultsWe successfully analyzed data from 28 (82%) patients. Median age was 58 years (IQR, 52-65), median eGFR was 95 ml/min per 1.73 m2 (IQR, 74-100) using the CKD-EPI formula, 30% had microalbuminuria, and 32% had diabetes. The model showed a mean Pglom of 48.0 mm Hg (SD=10.1) at baseline. Under hyperemia, flow increased by 88% (95% CI, 68% to 111%). This resulted in a 165% (95% CI, 79% to 294%) increase in afferent compliance and a 13.1-mm Hg (95% CI, 10.0 to 16.3) decrease in Pglom. In multiple linear regression analysis, diabetes (coefficient, 10.1; 95% CI, 5.1 to 15.1), BMI (0.99 per kg/m2; 95% CI, 0.38 to 1.59), and renal perfusion pressure (0.42 per mm Hg; 95% CI, 0.25 to 0.59) were significantly positively associated with baseline Pglom.ConclusionsWe constructed a model on the basis of proximal renal arterial pressure and flow velocity measurements that provides an overall estimate of glomerular pressure and afferent and efferent resistance in humans. The model provides a novel research technique to evaluate the hemodynamics of CKD on the basis of direct pressure and flow measurements.Clinical trial registry name and registration numberFunctional HEmodynamics in patients with and without Renal Artery stenosis (HERA), NL40795.018.12 at the Dutch national trial registry (toetsingonline.nl).

Project description:Background: The non-invasive estimation of aortic systolic (aoSBP) and pulse pressure (aoPP) is achieved by a great variety of devices, which differ markedly in the: 1) principles of recording (applied technology), 2) arterial recording site, 3) model and mathematical analysis applied to signals, and/or 4) calibration scheme. The most reliable non-invasive procedure to obtain aoSBP and aoPP is not well established. Aim: To evaluate the agreement between aoSBP and aoPP values invasively and non-invasively obtained using different: 1) recording techniques (tonometry, oscilometry/plethysmography, ultrasound), 2) recording sites [radial, brachial (BA) and carotid artery (CCA)], 3) waveform analysis algorithms (e.g., direct analysis of the CCA pulse waveform vs. peripheral waveform analysis using general transfer functions, N-point moving average filters, etc.), 4) calibration schemes (systolic-diastolic calibration vs. methods using BA diastolic and mean blood pressure (bMBP); the latter calculated using different equations vs. measured directly by oscillometry, and 5) different equations to estimate bMBP (i.e., using a form factor of 33% ("033"), 41.2% ("0412") or 33% corrected for heart rate ("033HR"). Methods: The invasive aortic (aoBP) and brachial pressure (bBP) (catheterization), and the non-invasive aoBP and bBP were simultaneously obtained in 34 subjects. Non-invasive aoBP levels were obtained using different techniques, analysis methods, recording sites, and calibration schemes. Results: 1) Overall, non-invasive approaches yielded lower aoSBP and aoPP levels than those recorded invasively. 2) aoSBP and aoPP determinations based on CCA recordings, followed by BA recordings, were those that yielded values closest to those recorded invasively. 3) The "033HR" and "0412" calibration schemes ensured the lowest mean error, and the "033" method determined aoBP levels furthest from those recorded invasively. 4) Most of the non-invasive approaches considered overestimated and underestimated aoSBP at low (i.e., 80 mmHg) and high (i.e., 180 mmHg) invasive aoSBP values, respectively. 5) The higher the invasively measured aoPP, the higher the level of underestimation provided by the non-invasive methods. Conclusion: The recording method and site, the mathematical method/model used to quantify aoSBP and aoPP, and to calibrate waveforms, are essential when estimating aoBP. Our study strongly emphasizes the need for methodological transparency and consensus for the non-invasive aoBP assessment.

Project description:BackgroundBlood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.MethodsA retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be < 20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and < 10mmHg for mean arterial pressure (MAP). The primary outcome was "pairwise agreement", i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.ResultsThere were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP < 90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio [aOR] 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP > 160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and agreement between the methods for SBP, DBP, or MAP.ConclusionsNon-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allow.

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Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity.

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Prognostic relevance of elevated pulmonary arterial pressure assessed non-invasively: Analysis in a large patient cohort with invasive measurements in near temporal proximity.

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