Beta-blockers use in patients with post-capillary pulmonary hypertension: insights from the multicentre prospective PH-HF study
C Fauvel, P De Groote, J C Eicher, T Damy, E Berthelot, J N Trochu, D Logeart, F Picard, S Renard, H Bouvaist, F Roubille, O Sitbon, F Bauer, N LamblinAbstract
Background
The benefit of beta-blockers (BB) in patients with post-capillary pulmonary hypertension (pcPH) due to either heart failure with preserved (HFpEF) or reduced (HFrEF) ejection fraction, remains unclear, especially in case of right ventricular (RV) dysfunction.
AIMS
To assess the benefit of BB in patients with PH-HFpEF and PH-HFrEF and their impact of haemodynamic data.
Methods
All patients with pcPH (mean pulmonary artery pressure [mPAP] ≥20 mmHg and pulmonary artery wedge pressure [PAWP] >15 mmHg in right heart catheterization) from the French prospective and multicentric PH-HF cohort were included in this analysis. Afterwards, patients were classified as PH-HFpEF when left ventricular ejection fraction (LVEF) was ≥50% or PH-HFrEF otherwise. RV dysfunction was defined as TAPSE/sPAP ratio ≤ 0.33 mm/mmHg (a surrogate for RV to pulmonary artery [RVPA] uncoupling). The primary composite endpoint was 3-years all-cause death or hospitalization due to acute heart failure (HF).
Results
The PH-HFpEF and PH-HFrEF groups included respectively 268 patients (n=169, 63% with BB) and 338 patients (n=284, 84% with BB). When present, the BB dose was higher in the PH-HFrEF group (p=0.02). At 3-years, the primary endpoint occured in 36% and 49% of patients in the PH-HFpEF and PH-HFrEF group, respectively. In the PH-HFpEF group, patients with BB were more likely to have atrial fibrillation (p=0.02), and no differences regarding demographic, clinical or echocardiographic data. Regarding haemodynamic data, patients with BB from this group had similar mPAP (p=0.3), PAWP (p=0.2) and pulmonary vascular resistance (PVR, p=0.2) but lower cardiac index (CI, p=0.014), higher PA pulsatility index (PAPi, p=0.02) and wedge to right atrial pressure ratio (p=0.006). In the PH-HFrEF group, patients with BB had lower LVEF (p=0.03), higher LV dilatation (p<0.001), higher TAPSE/sPAP ratio (p=0.034). Regarding haemodynamic data, patients with BB had lower mPAP (p=0.003) and PVR (p=0.02), but similar CI (p=0.8) and PAWP (p=0.08). In both group, even when PVR were ≥ 2 WU or in case of RV-PA uncoupling, the use of BB was not associated with worse survival. BB might even be beneficial in patients with PH-HFrEF and RV-PA uncoupling (Figure).
Conclusion
In patients with pcPH, the use of BB in patients was associated with different haemodynamic pattern between PH-HFpEF or PH-HFrEF but appears to be safe and not associated with worse survival, even in the presence of RV-PA uncoupling or elevated PVR.Survival curvesFor image description, please refer to the figure legend and surrounding text.