Determinants and prognostic significance of exercise pulmonary hypertension in asymptomatic severe aortic stenosis

Recent studies emphasized the usefulness of exercise stress echocardiography in asymptomatic patients with aortic stenosis. Nevertheless, the additive value of exercise pulmonary hypertension (Ex-PHT) in such patients remains unexplored. We therefore aimed to identify the determinants and to test th...

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Published in:Circulation (New York, N.Y.) Vol. 126; no. 7; p. 851
Main Authors: Lancellotti, Patrizio, Magne, Julien, Donal, Erwan, O'Connor, Kim, Dulgheru, Raluca, Rosca, Monica, Pierard, Luc A
Format: Journal Article
Language:English
Published: United States 14.08.2012
Subjects:
Aged
Aged, 80 and over
Aortic Valve Stenosis - diagnostic imaging
Arterial Pressure
Echocardiography, Stress - methods
Exercise Test - methods
Female
Heart Ventricles - diagnostic imaging
Heart Ventricles - physiopathology
Humans
Hypertension, Pulmonary - diagnostic imaging
Male
Middle Aged
Prognosis
Pulmonary Wedge Pressure
Severity of Illness Index
Sex Factors
Stroke Volume
ISSN:1524-4539, 1524-4539
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Summary:Recent studies emphasized the usefulness of exercise stress echocardiography in asymptomatic patients with aortic stenosis. Nevertheless, the additive value of exercise pulmonary hypertension (Ex-PHT) in such patients remains unexplored. We therefore aimed to identify the determinants and to test the impact on outcome of Ex-PHT in asymptomatic patients with severe aortic stenosis. Asymptomatic patients with severe aortic stenosis (n=105; aortic valve area <0.6 cm(2)/m(2); age, 71±9 years; male, 59%) and preserved left ventricular systolic function (ejection fraction ≥55%) were prospectively submitted to exercise stress echocardiography. Resting PHT and Ex-PHT were defined as a systolic pulmonary arterial pressure >50 and >60 mm Hg, respectively. Ex-PHT was more frequent than resting PHT (55% versus 6%; P<0.0001). On multivariable logistic regression, the independent predictors of Ex-PHT were male sex (odds ratio, 4.3; P=0.002), resting systolic pulmonary arterial pressure (odds ratio, 1.16; P=0.002), exercise indexed left ventricular end-diastolic volume (odds ratio, 1.04; P=0.026), exercise e'-wave velocity (odds ratio, 1.35; P=0.047), and exercise-induced changes in indexed left atrial area (odds ratio, 1.36; P=0.006). Ex-PHT was associated with reduced cardiac event-free survival (at 3 years, 22±7% versus 55±9%; P=0.014). In a multivariable Cox proportional hazards model, Ex-PHT was identified as an independent predictor of cardiac events (hazard ratio, 1.8; 95% confidence interval, 1.0-3.3; P=0.047). When exercise-induced changes in mean aortic pressure gradient were added to the multivariable model, Ex-PHT remained independently associated with reduced cardiac event-free survival (hazard ratio, 2.0; 95% confidence interval, 1.1-3.6; P=0.025). In asymptomatic patients with severe aortic stenosis, the main determinants of Ex-PHT are male sex, resting systolic pulmonary arterial pressure, and exercise parameters of diastolic burden. Moreover, Ex-PHT is associated with a 2-fold increased risk of cardiac events. These results strongly support the use of exercise stress echocardiography in asymptomatic aortic stenosis.
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ISSN:1524-4539
1524-4539
DOI:10.1161/CIRCULATIONAHA.111.088427