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Acute Vasodilator Challenge Testing In Patients With Heart Failure With Preserved Ejection Fraction

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Conference: 2014 International PHA Conference and Scientific Sessions

Release Date: 06.22.2014

Presentation Type: Abstracts

File Download: 2014 Conference Abstract - Nadine Al-Naamani

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Group 2 pulmonary hypertension (PH) in patients with heart failure with preserved ejection fraction (HFpEF) is an increasingly recognized entity associated with a worse prognosis. The role of acute vasodilator challenge is well established in Group 1 pulmonary arterial hypertension, but not in Group 2 PH.

Background: Group 2 pulmonary hypertension (PH) in patients with heart failure with preserved ejection fraction (HFpEF) is an increasingly recognized entity associated with a worse prognosis. The role of acute vasodilator challenge is well established in Group 1 pulmonary arterial hypertension, but not in Group 2 PH. The aim of this study was to compare the acute hemodynamic response to two vasodilators: inhaled nitric oxide (INO) and sodium nitroprusside (SNP) in patients with Group 2 PH-HFpEF.

Methods: We performed a cross-sectional analysis of a prospective cohort of Group 2 PH patients who presented for right heart catheterization at Tufts Medical Center from March 2010 – May 2013. Adult patients with mean pulmonary artery pressure (mPAP) >25 mmHg, pulmonary capillary wedge pressure (PCWP) >15 mmHg and preserved ejection fraction by echocardiogram (>50%) who had undergone both INO and SNP challenge in the cardiac catheterization laboratory were included. INO was administered first at 10-20 ppm. Next, SNP was titrated to maintain a systolic blood pressure >100 mmHg. To ensure recovery to baseline hemodynamics, there was >15 min between vasodilator administrations. Values are reported as means ± SD. Repeated measures analyses was used to assess the differences between means. 

Results: The study sample included 8 patients with Group 2 PH-HFpEF who had undergone INO and SNP challenge testing. The mean age was 64 ± 14 years, 88% were female and mean body mass index was 41 ± 17 kg/m2. The dose of SNP ranged between 0.25 to 2 mcg/kg/min. SNP decreased significantly mean PA pressure, pulmonary artery capacitance (PAC), pulmonary vascular resistance (PVR) and mean arterial pressure (MAP), when compared to baseline and INO. As expected, there was a trend toward lower systemic vascular resistance (SVR) with SNP, without the occurrence of symptomatic hypotension. There was a significant decrease in transpulmonary gradient with both vasodilators; however the diastolic pulmonary gradient and PVR/SVR ratio only decreased significantly with INO.

 

Baseline

INO

SNP

p for trend

mPAP, mmHg

45 ± 10

42 ± 11

34 ± 11

0.002

Cardiac index, L/min/m2

2.51 ± 0.74

2.45 ± 0.75

2.56 ± 0.39

0.74

PCWP, mmHg

23 ± 2

26 ± 6

20 ± 5

0.06

Transpulmonary gradient, mmHg

29 ± 9

16 ± 10

14 ± 10

0.001

Pulmonary diastolic gradient, mmHg

8 ± 5

2 ± 4

4 ± 6

0.004

PAC, ml/mmHg

2.4 ± 1.5

2.8 ± 2.2

3.5 ± 2.5

0.04

PVR, WU

6.5 ± 7.8

3.6 ± 3.4

4.4 ± 6.4

0.001

SVR, WU

20.1 ± 12.4

20.2 ± 15.9

12.9 ± 3.8

0.12

PVR/SVR

0.27 ± 0.13

0.16 ± 0.07

0.27 ± 0.29

0.25

Mean arterial pressure, mmHg

102 ± 16

106 ± 16

79 ± 12

0.001

Conclusions: Acute vasodilator challenge testing with sodium nitroprusside in patients with Group 2 PH/HFpEF has greater hemodynamic effects when compared to inhaled nitric oxide. Prospective follow-up of these patients is needed to determine the ability of acute vasodilator challenge response to sodium nitroprusside in predicting outcomes in this population.Acute vasodilator challenge testing with sodium nitroprusside in patients with Group 2 PH/HFpEF has greater hemodynamic effects when compared to inhaled nitric oxide. Prospective follow-up of these patients is needed to determine the ability of acute vasodilator challenge response to sodium nitroprusside in predicting outcomes in this population. Acute vasodilator challenge testing with sodium nitroprusside in patients with Group 2 PH/HFpEF has greater hemodynamic effects when compared to inhaled nitric oxide. Prospective follow-up of these patients is needed to determine the ability of acute vasodilator challenge response to sodium nitroprusside in predicting outcomes in this population.

Type: Clinical Science