Pulmonary artery Pulsatility index and compliance for hemodynamic risk classification in heart failure

Right ventricular (RV) dysfunction and elevated RV afterload frequently coexist in heart failure (HF) and are associated with adverse outcomes. Pulmonary artery pulsatility index (PAPi) and pulmonary arterial capacitance (PAC) reflect RV function and afterload, respectively; however, their combined prognostic value and optimal cutoff values remain unestablished. We aimed to define clinically relevant cutoff values and assess their prognostic performance.

We retrospectively analyzed the data from 464 patients with compensated HF who underwent right heart catheterization between 2016 and 2019. Optimal prognostic cutoff values of PAPi and PAC were derived using a grid search with bootstrap resampling. The primary endpoint was a composite of cardiovascular death or HF hospitalization. Prognostic performance was compared with established hemodynamic classifications.

During a median follow-up of 3.4 years, 132 patients (28.4 %) experienced the primary endpoint. The optimal cutoff values were 1.67 and 3.08 for PAPi and PAC, respectively. Compared with PAPi ≥1.67/PAC ≥3.08, the adjusted hazard ratios (95 % confidence interval [CI]) were 2.292 (1.280-4.103) for PAPi <1.67/PAC ≥3.08, 2.644 (1.541-4.537) for PAPi ≥1.67/PAC <3.08, and 4.622 (2.500-8.547) for PAPi <1.67/PAC <3.08. The PAPi-PAC model showed the highest concordance index (C-index, 0.723, 95 % CI: 0.672-0.774) and largest improvement over the basic model (ΔC-index, 0.052, P = 0.002), outperforming conventional hemodynamic models.

A classification based on PAPi and PAC cutoff values provided robust risk stratification in HF and showed improved prognostic performance compared with conventional hemodynamic models.