Clinical characteristics
The clinical characteristics of the 66 patients with a sPAP ≥40mmHg and of the 96 patients with a sPAP<40mmHg are shown in Table 1.
Table 1
Demographic and clinical characteristics of the study patients, comparing patients with systolic arterial pulmonary pressure (sPAP) ≧40 mmHg and sPAP <40 mmHg
|
sPAP≧40 mmHg(n=66)
|
sPAP <40 mmHg
(n=96)
|
P-value
|
Demographics
Age, year
|
84.4±2.8
|
83.7±2.8
|
0.089
|
Gender, male
|
32(48.5)
|
58(60.4)
|
0.133
|
Weight, kg
|
70.7±15.4
|
73.2±12.0
|
0.265
|
Height, cm
|
167.6±22.2
|
169.5±8.8
|
0.452
|
BMI, kg/m2
|
23.6±3.7
|
25.4±3.8
|
0.004
|
Smoking, yes
|
6(9.5)
|
5(5.3)
|
0.321
|
Clinical Characteristics
STEMI, yes
|
28(42.4)
|
38(39.6)
|
0.421
|
Non-STEMI, yes
|
31(47.0)
|
48(50.0)
|
0.413
|
PCI, yes
|
44(66.7)
|
77(80.2)
|
0.051
|
Heart rate,bpm
|
81.8±16.7
|
80.8±29.7
|
0.881
|
Systolic BP, mmHg
|
145.6±28.6
|
150.4±26.6
|
0.296
|
Diastolic BP, mmHg
|
85.8±16.1
|
82.8±16.1
|
0.271
|
Laboratory findings
Hemoglobin, g/L
|
129.8±15.2
|
131.7±17.0
|
0.478
|
eGFR, ml/min/1.73m2
|
49.1±19.7
|
50.3±18.3
|
0.682
|
Creatinine, umol/L
|
110.0±104.2
|
110.7±77.6
|
0.961
|
Comobidities
Atrial fibrillation, yes
|
17(27.0)
|
17(17.7)
|
0.153
|
History of heart failure, yes
|
14(23.0)
|
17(17.7)
|
0.355
|
Hypertension, yes
|
35(53.0)
|
40(41.7)
|
0.103
|
Diabetes, yes
|
13(21.0)
|
16(17.6)
|
0.374
|
Hyperlipidaemia, yes
|
9(13.8)
|
8(8.3)
|
0.195
|
Previous stroke, yes
|
11(19.6)
|
10(11.0)
|
0.284
|
Medications
β- Blockers, yes
|
34(51.5)
|
51(56.7)
|
0.317
|
ACEI/ARB, yes
|
20(30.3)
|
26(27.1)
|
0.517
|
diuretics, yes
|
16(24.2)
|
19(20.9)
|
0.378
|
Calcium channel blocker, yes
|
14(21.2)
|
36(39.1)
|
0.017
|
Statins, yes
|
11(16.7)
|
21(22.6)
|
0.238
|
Digoxin, yes
|
9(15.0)
|
10 (10.8)
|
0.296
|
BMI, body mass index. STEMI, ST-elevation myocardial infarction. Non-STEMI, Non-ST-elevation myocardial infarction. PCI, percutaneous coronary intervension. BP, blood pressure. eGFR, estimated glomerular filtration rate. ACEI, angiotensin converting enzyme inhibitors. ARB, angiotensin receptor blockers. |
Patients with sPAP >40mmHg had lower BMI (23.6±3.7 vs. 25.4±3.8 kg/m2) and were less frequently treated with calcium channel blocker (21.2% vs.39.1%) compared to patients with a sPAP<40mmHg.There were no significant differences in gender, previous stroke or in number of patients treated with PCI, betablockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, diuretics, statins or digoxin.
Echocardiographic findings
The lowest cut-off level of sPAP over which increasing sPAP was associated with increased mortality rate was 40 mmHg. Patients with sPAP ≥40mmHgmore often had reduced LVEF (41.7% vs. 49.5%),elevated left ventricular filling pressure (43.9% vs. 21.6%), dilated left atrium (54.2% vs. 33.0%), mitral valve regurgitation (56.9% vs. 25.0%), tricuspid valve regurgitation(13.8% vs. 4.4%) and aortic valve stenosis (27.6% vs. 13.3%)compared to patients with sPAP <40 mmHg, Table 2.
Table 2
Echocardiographic characteristics of study patients, comparing patients with systolic arterial pulmonary pressure (sPAP) ≥40 mmHg and sPAP <40 mmHg
|
sPAP≧40 mmHg(n=66)
|
sPAP <40 mmHg
(n=96)
|
P-value
|
Left ventricular ejection fraction, %
|
41.7±10.6
|
49.5±10.4
|
<0.001
|
Elevated left ventricular filling pressure, yes
|
29(43.9)
|
16(21.6)
|
<0.001
|
Dilated left ventricle, yes
|
16(25.4)
|
15(16.5)
|
0.125
|
Dilated left atrium, yes
|
32(54.2)
|
29(30.2)
|
0.008
|
Mitral valve regurgitation≥ grad 1/4, yes
|
37(56.9)
|
23(25.0)
|
<0.001
|
Tricuspid valve regurgitation≥ grad 1/4, yes
|
9(13.8)
|
4(4.4)
|
0.036
|
Aortic valve stenosis, yes
|
16(27.6)
|
11 (13.3)
|
0.029
|
Outcome data
After 5-years of follow-up 86 patients died (all-cause mortality: 53.0%) while the 1-year all-cause mortality was 23.4% (38deaths). Patients with sPAP ≥40mmHg had a higher 5-year mortality rate, of 69.6% (46 events) and 1-year mortality rate, of 34.8%( 23 events), compared to patients with sPAP<40 mmHg, 41.6% (40 events) (p<0.001) for 5-year mortality rate and 15.6% (15 events) (p=0.004) for 1-year mortality rate.
Association between sPAP and 1-year mortality
Table 3 illustrated the association between sPAP and 1-year all-cause mortality.
Table 3
Univariate and multivariable Cox-regression analysis of factors for association with1-year all-cause mortality.
Variables
|
Univariable
|
Multivariable
|
HR
|
(95%CI)
|
p
|
HR
|
(95%CI)
|
p
|
Age, year
|
1.03
|
0.92-1.15
|
0.602
|
0.97
|
0.85-1.11
|
0.639
|
Gender, male
|
0.79
|
0.42-1.49
|
0.471
|
0.97
|
0.31-0.90
|
0.518
|
sPAP ≥ 40mmHg
|
2.46
|
1.26-4.62
|
0.008
|
2.63
|
1.19-5.84
|
0.017
|
LVEF≤ 45%
|
1.71
|
0.88-3.29
|
0.111
|
1.34
|
0.61-2.93
|
0.469
|
Diabetes Mellitus
|
1.26
|
0.57-2.75
|
0.570
|
1.17
|
0.49-2.77
|
0.727
|
Treatment with percutaneous coronary intervention (PCI)
|
0.56
|
0.29-1.09
|
0.086
|
0.72
|
0.33-1.6
|
0.424
|
Atrial fibrillation
|
0.89
|
0.39-2.05
|
0.791
|
0.78
|
0.31-1.96
|
0.601
|
Estimated glomerular filtration rate ≤35 ml/min
|
1.94
|
0.96-3.95
|
0.067
|
1.99
|
0.88-4.48
|
0.097
|
HR, Hazard ratio. sPAP, systolic pulmonary arterial pressure. LVEF, left ventricular ejection fraction. |
Multivariable analysis demonstrated an association between elevated sPAP and increased 1-year all-cause mortality rate with a cutoff level at >40 mmHg (HR 2.63, 95%CI 1.19-5.84, p=0.017), Figure 1.
As a continuous variable, every increase of 5 mmHg in sPAP was associated with 2.5% increased relative risk for all-cause mortality (HR = 1.02, 95% of CI 1.00–1.05 and p=0.05).
Association between s PAP and 5-year mortality
Table 4 illustrated the association between sPAP and 5-year mortality.
Table 4
Univariate and multivariable cox-regression analysis of factors for association with 5-year all-cause mortality.
Variables
|
Univariable
|
Multivariable
|
HR
|
(95%CI)
|
p
|
HR
|
(95%CI)
|
p
|
Age, year
|
1.09
|
1.01-1.17
|
0.021
|
1.02
|
0.93-1.11
|
0.693
|
Gender, male
|
0.97
|
0.64-1.49
|
0.891
|
1.9
|
1.1-3.2
|
0.019
|
sPAP ≥ 40mmHg
|
2.21
|
1.44-3.38
|
<0.001
|
2.08
|
1.25-3.44
|
0.005
|
LVEF≤ 45%
|
1.26
|
0.82-1.92
|
0.293
|
1.42
|
0.85-2.438
|
0.158
|
Diabetes Mellitus
|
1.92
|
1.17-3.14
|
0.010
|
1.73
|
1.01-2.96
|
0.048
|
Treatment with percutaneous coronary intervention (PCI)
|
0.445
|
0.29-0.69
|
<0.001
|
0.48
|
0.29-0.82
|
0.004
|
Atrial fibrillation
|
2.32
|
1.47-43.67
|
<0.001
|
2.04
|
1.22-3.40
|
0.006
|
Estimated glomerular filtration rate ≤35 ml/min
|
2.19
|
1.36-3.54
|
0.001
|
2.35
|
1.37-4.01
|
0.006
|
HR= Hazard ratio. sPAP= systolic pulmonary arterial pressure. LVEF= left ventricle ejection fraction. |
Cox proportional-hazard regression multivariable models adjusted for important clinical variables and all significant variables from univariable models demonstrated an association between elevated sPAP and increased all-cause mortality rate with a cutoff level at ≥40 mmHg (HR =2.08, 95%CI 1.25-3.44, p=0.005, Figure 2).
As a continuous variable, every increase of 5 mmHg in sPAP was associated with 3% increased relative risk for all-cause mortality (HR = 1.03, 95% of CI = 1.01–1.04 and p = 0.003). Also male gender (HR 1.9, 95%CI 1.1-3.2, p=0.019), atrial fibrillation (HR 2.04, 95%CI 1.22-3.40, p=0.006) and eGFR≤35 ml/min/1.73m2 (HR 2.35, 95%CI 1.37-4.01, p=0.006) were associated with increased 5-year mortality rate. Treatment with percutaneous coronary intervention were associated with decreased 5-year mortality, (HR 0.48, 95%CI 0.29-0.82, p=0.004).