Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure

Background: Elevated left ventricular filling pressures present a major target of therapy for symptomatic heart failure but are difficult to assess directly. Because the relationship of left- and right-sided pressures remains ill defined in chronic heart failure, this study compared 3 right-sided measurements (right atrial [RA] pressure, pulmonary artery systolic [PAS] pressure, and severity of tricuspid regurgitation [TR]) to the pulmonary capillary wedge (PCW) pressure; Methods: Hemodynamic measurements and echocardiography were available from 1000 patients undergoing transplant evaluation. Right atrial and PAS pressure, and TR severity were compared to PCW pressure, For 754 patients undergoing repeat measurements, changes in RA and PAS pressures were compared to PCW changes. Results: Right atrial pressure correlated with PCW pressure (r = 0.64), regardless of etiology or TR severity. Right atrial pressure changes correlated with PCW changes (r = 0.62). Discordance was defined as either RA greater than or equal to 10 mm Hg despite PCW < 22 mm Hg (6%) or RA < 10 mm Hg despite PCW greater than or equal to 22 mm Hg (15%). For detection of PCW greater than or equal to 22 mm. Hg, positive predictive values were 88% for RA greater than or equal to 10 mm Hg, 95% for PAS greater than or equal to 60 mm Hg, and 79% for greater than or equal to moderate TR. Pulmonary artery systolic pressure correlated very closely with PCW (r = 0.79), and could be estimated as 2 x PCW. Reduction in PAS pressure during therapy was strongly determined by PCW pressure reduction (r = 0.67). Conclusions: Accurate estimation of RA pressure can potentially guide therapy of left ventricular filling pressures in approximately 80% of chronic heart failure patients without: obvious non-cardiac disease. In this population, elevated PAS pressures are largely determined by elevated left-sided filling pressures.