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Original Research: Pulmonary Vascular Disease |

Clinical Relevance of Fluid Challenge in Patients Evaluated for Pulmonary Hypertension FREE TO VIEW

Michele D'Alto, MD, PhD; Emanuele Romeo, MD, PhD; Paola Argiento, MD, PhD; Yoshiki Motoji, MD, PhD; Anna Correra, MD; Giovanni Maria Di Marco, MD; Agostino Mattera Iacono, MD; Rosaria Barracano, MD; Antonello D'Andrea, MD, PhD; Gaetano Rea, MD; Berardo Sarubbi, MD, PhD; Maria Giovanna Russo, MD; Robert Naeije, MD, PhD
Author and Funding Information

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

aDepartment of Cardiology, Second University of Naples, Naples, Italy

bDepartment of Pathophysiology, Free University of Brussels, Brussels, Belgium

cDepartment of Radiology, Monaldi Hospital, Naples, Italy

CORRESPONDENCE TO: Michele D’Alto, MD, PhD, Department of Cardiology, Second University of Naples, Piazzale Ettore Ruggieri, 1, Naples 80128, Italy


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(1):119-126. doi:10.1016/j.chest.2016.08.1439
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Background  Fluid challenge may help in the differential diagnosis between pre- and postcapillary pulmonary hypertension (PH). However, the test is still in need of standardization and better defined clinical relevance.

Methods  Two hundred twelve patients referred for PH underwent a right-sided heart catheterization with measurements before and after rapid infusion of 7 mL/kg of saline. PH was defined as mean pulmonary artery pressure ≥ 25 mm Hg, and postcapillary PH was defined as pulmonary artery wedge pressure (PAWP) > 15 mm Hg. An increase in PAWP ≥ 18 mm Hg was considered diagnostic for postcapillary PH. At baseline, 66 patients received a diagnosis of no PH; 22, of postcapillary PH; and 124, of precapillary PH (mostly pulmonary arterial hypertension).

Results  After fluid challenge, five of 66 patients with no PH (8%) and eight of 124 with precapillary PH (6%) had the diagnosis reclassified as postcapillary PH. Fluid challenge was associated with an increase in PAWP by 7 ± 2 mm Hg in postcapillary PH and 3 ± 1 mm Hg in both precapillary PH and no-PH groups. Between-group differences were significant, but there was overlap. There were no adverse events related to fluid challenge. Prediction bands calculated from quadratic fits of the PAWP responses in pooled control subjects with no PH and patients with precapillary PH helped confirm 18 mm Hg as the cutoff for diagnosing postcapillary PH.

Conclusions  Fluid challenge with 7 mL/kg saline increases PAWP, more in postcapillary than in precapillary PH or in control subjects with no PH. A cutoff value of 18 mm Hg allows reclassification of 6% to 8% of patients with precapillary PH or normal hemodynamic characteristics at baseline.

Figures in this Article

The current classification of pulmonary hypertension (PH) recognizes five groups diagnosed on the basis of a step-by-step clinical probability assessment and eventual invasive measurements of pulmonary vascular pressures and cardiac output.,, So far, the most common form of PH is group 2, consisting of patients having left-sided heart disease (LHD) as a cause of increased pulmonary venous pressure. In these patients, PH is postcapillary and diagnosed with a mean pulmonary artery pressure (PAP) ≥ 25 mm Hg and a pulmonary artery wedge pressure (PAWP) > 15 mm Hg.,, However, PAWP in PH-LHD may be found below the 15 mm Hg threshold in the resting state in patients with optimal therapy and volume depletion on diuretic intake. In these patients, fluid challenge with rapid infusion of saline may reveal an abnormally high PAWP.,,,

There has been hesitation about the amount of volume loading and PAWP cutoff values, but agreement is emerging about 500 mL of saline administered over 5 to 10 min and a PAWP of 18 mm Hg as an upper limit of a normal response. However, uncertainty remains about the added value of fluid challenge in routine hemodynamic workup in patients referred for PH., We therefore investigated the clinical relevance of a fluid challenge systematically added to standard right-sided heart catheterization measurements in patients referred for a suspicion or an evaluation of PH and related the observed hemodynamic response to the different PH groups.

This was a prospective single-center study. All consecutive patients referred to the Pulmonary Hypertension Unit of Monaldi Hospital, Naples, Italy, between January 1, 2014, and December 31, 2015, to undergo right-sided heart catheterization for suspicion or evaluation of PH were enrolled in the study. All consecutive adult patients undergoing catheter ablation for supraventricular tachycardia in the department of cardiology of the same hospital were considered a control group. The presence of an uncorrected intra- or extracardiac shunt and the presence of atrial fibrillation or flutter were considered exclusion criteria. All patients provided informed consent, and the study was approved by the Institutional Review Board at Monaldi Hospital (No. 774/15).

The patients underwent a step-by-step diagnostic workup in agreement with current guidelines, thus including clinical evaluation, lung function tests, echocardiography, and ventilation-perfusion scanning; an invasive evaluation was used only if thought to be clinically relevant., Right-sided heart catheterization was performed without sedation by two experienced cardiologists (M. D. and E. R.). Measurements of right atrial pressure (RAP), right ventricular pressure, PAP, and PAWP were obtained at end expiration. Cardiac output was measured by means of thermodilution by using an average of at least three measurements. Pulmonary vascular resistance (PVR) was calculated as mean PAP minus PAWP (transpulmonary pressure gradient [TPG]) divided by cardiac output. The diastolic pressure gradients (DPGs) were calculated as diastolic PAP minus PAWP. A transmural left ventricular filling pressure was estimated by using the gradient between PAWP and RAP. PH was defined as a mean PAP ≥ 25 mm Hg. Postcapillary PH was defined by a PAWP > 15 mm Hg.

Hemodynamic measurements were obtained at baseline and immediately after intravenous administration of 7 mL/kg of saline over 5 to 10 min. Fluid challenge was normalized to body weight to avoid excessive disparities between large and small patients. It was estimated that 7 mL/kg would correspond on average to 500 mL because larger volumes might not be tolerated by patients with left-sided heart conditions.,,,,

Fluid challenge in patients with a PAWP > 25 mm Hg due to heart failure was avoided because of the high risk of pulmonary edema. All patients with idiopathic, familial, or drug-associated pulmonary arterial hypertension (PAH) underwent vasoreactivity testing with nitric oxide 20 parts per million. In the control group, a right-sided heart catheterization with the measurement of hemodynamic characteristics at baseline and after fluid challenge was performed at the end of the electrophysiologic procedure. Patients with baseline hemodynamic characteristics excluding PH or consistent with precapillary PH who developed a PAWP ≥ 18 mm Hg were classified as having hidden postcapillary PH or hidden PH-LHD.

Results are reported as mean ± SD unless otherwise noted. Between-group differences were compared by using Kruskal-Wallis tests. Data for categorical variables were calculated by using a Student-Newman-Keuls test. Prediction bands (Spred) were calculated based on a quatratic fit of the pooled PAWP and RAP responses to volume loading in control subects with no PH and patients with PH by using the following equation:

Statistical analysis was performed using MedCalc 16.4.3 (MedCalc Software).

The demographic and clinical characteristics of the 212 patients included in the study are presented in Table 1. There were 61 control subjects with no PH, 116 patients with precapillary PH (103 with PAH, nine with lung-disease-related PH group 3, and four with chronic thromboembolic PH [CTEPH]), 22 patients with PH-LHD, and 13 patients with hidden PH-LHD. After fluid challenge, eight of 111 patients (7%) initially classified as having PAH and five of 66 patients (8%) with no PH had developed a PAWP ≥ 18 mm Hg and had their diagnoses reclassified as hidden PH-LHD. The 13 patients with hidden PH-LHD were older and had a higher prevalence of hypertension, hyperlipidemia, diabetes, coronary artery disease, and obstructive sleep apnea than did those with PAH or normal pulmonary hemodynamic characteristics. Moreover, echocardiographic features typical for group 2 PH, such as left atrial enlargement and left ventricular hypertrophy, were more common in patients with hidden PH-LHD than in patients with precapillary PH or control subjects with no PH.

Table Graphic Jump Location
Table 1 Baseline Demographic Characteristics, Comorbidities, and Echocardiographic Findings
a Patients reclassified as having PH due to LHD after a fluid challenge test.
b P < .05 vs no PH.

LHD = left-sided heart disease; LV = left ventricular; PH = pulmonary hypertension.

The baseline hemodynamic characteristics of the patients are shown in Table 2. BP and heart rate were not different between groups. RAP, PAP, PVR, and TPG were higher and the cardiac index lower in the patients with PH than in the control subjects with no PH. Patients with PH-LHD had higher PAWP. The DPG was higher in patients with PAH, group 3 PH or CTEPH than in control subjects or patients with PH-LHD. The PAWP-RAP difference was higher in patients with overt PH-LHD but also, though to a lesser extent, in those with hidden PH-LHD.

Table Graphic Jump Location
Table 2 Baseline Hemodynamic Characteristics
a P < .05 vs no PH.

CTEPH = chronic thromboembolic PH; DPG = diastolic pressure gradient; PAH = pulmonary arterial hypertension; PAP = pulmonary artery pressure; PAWP = pulmonary artery wedge pressure; PVR = pulmonary vascular resistance; RAP = right atrial pressure; RV = right ventricular; TPG = transpulmonary pressure gradient; WHO-FC = World Health Organization functional class. See Table 1 legend for expansion of other abbreviations.

The total amount of fluid administered was 478 ± 87 mL for all the patients and was not different between the groups. An average of 40% of the patients received more than 500 mL. The hemodynamic characteristics after the fluid challenge are shown in Table 3, with changes in Table 4. Cardiac index, RAP, PAP, and PAWP increased and PVR decreased in all the groups. The DPG and the TPG decreased in patients with overt as well as hidden PH-LHD and otherwise increased (PAH) or remained unchanged. The increases in PAWP and PAWP-RAP were proportionally larger in patients with PH-LHD. The PAWP-RAP gradient did not change in control subjects with no PH and in patients with CTEPH, decreased in patients with PAH and patients in group 3 by an average of 2 mm Hg, and increased by an average of 2 mm Hg in patients with overt PH-LHD and 4 mm Hg in hidden PH-LHD. However, absolute changes in PAWP-RAP were small with relatively large SDs.

Table Graphic Jump Location
Table 3 Hemodynamic Characteristics After Fluid Challenge
a P < .05 vs no PH.

Data are presented as mean ± SD. RA = right atrial. See Table 1 and 2 legends for expansion of other abbreviations.

Table Graphic Jump Location
Table 4 Fluid-Challenge-Induced Changes in Hemodynamic Characteristics
a P < .05 vs no PH.

Data are presented as mean ± SD. Δ = change between before and after fluid challenge. See Table 1 and 2 legends for expansion of other abbreviations.

The individual responses to the absolute amount of volume loaded and prediction bands in control subjects with no PH, patients with pooled precapillary PH, and patients with pooled postcapillary PH are shown in Figures 1 and 2. As the prediction bands show, the upper limits of normal for PAWP and RAP after fluid challenge were 18 and 12 mm Hg, respectively, at a normalized absolute volume of 500 mL.

Figure 1
Figure Jump LinkFigure 1 Individual increases in PAWP as a function of volume of rapidly infused saline 7 mL/kg in control subjects with no pulmonary hypertension (PH) (A), patients with precapillary PH (B), and patients with postcapillary PH (C). ● = patients with hidden left-sided heart disease defined by means of a fluid-challenge-induced increase in PAWP > 18 mm Hg. The shaded area corresponds to quadratic fits of the pooled PAWP responses. The horizontal dotted lines correspond to a predefined upper limit of normal of 18 mm Hg for PAWP after fluid challenge. The vertical dotted line corresponds to 500 mL of infused saline. PAWP = pulmonary wedge pressure.Grahic Jump Location
Figure 2
Figure Jump LinkFigure 2 Individual increases in RAP as a function of volume of rapidly infused saline 7 mL/kg in control subjects with no pulmonary hypertension (PH) (A), patients with precapillary PH (B), and patients with postcapillary PH (C). ● = patients with hidden left-sided heart disease defined by means of a fluid-challenge-induced increase in PAWP > 18 mm Hg. The shaded area corresponds to quadratic fits of the pooled RAP responses. The horizontal dotted line corresponds to the upper limit of normal of 12 mm Hg for RAP after fluid challenge. The vertical dotted line corresponds to 500 mL of infused saline. RAP = right atrial pressure. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location

Five of 66 control subjects with no PH (8%) and eight of 124 patients with precapillary PH (6%) had a PAWP ≥ 18 mm Hg after fluid challenge. These prevalences increased to 12% and 15%, respectively, with a PAWP cutoff value of 15 mm Hg. All of the patients with hidden PH-LHD of the precapillary PH group had PAH. All of the patients with PH-LHD had a PAWP ≥ 18 mm Hg after fluid challenge.

Four of the 61 control subjects with no PH reached the upper limit of normal for RAP of 12 mm Hg after fluid challenge. Most patients with pre- and postcapillary PH (61% and 86%, respectively) had a postfluid challenge RAP > 12 mm Hg.

The changes in PAWP and RAP in control subjects with no PH, patients with pooled precapillary PH, and patients with pooled postcapillary PH are shown in Figures 3 and 4. Postcapillary PH was associated with a significantly larger increase in PAWP than that seen in either control subjects or patients with precapillary PH. Most patients with hidden postcapillary PH were outliers. Both pre- and postcapillary PH were associated with a larger increase in RAP than that in control subjects, but without a difference between pre- and postcapillary PH.

Figure 3
Figure Jump LinkFigure 3 Boxplots showing increases in PAWP after a rapid infusion of 7 mL/kg saline; these increases were more important in patients with postcapillary PH than in patients with precapillary PH or control subjects with no PH. Six of the eight patients with hidden postcapillary PH from the precapillary PH group were outliers (X). **P < .01 compared with no PH. Δ = change; PH = pulmonary hypertension. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location
Figure 4
Figure Jump LinkFigure 4 Boxplots showing increases in RAP after a rapid infusion of 7 mL/kg saline; these increases were more important in patients with postcapillary PH or precapillary PH than in control subjects with no PH. Four of the 13 patients with hidden postcapillary PH were outliers (X). **P < .01 compared with no PH. See Figure 2 and 3 legends for expansion of abbreviations.Grahic Jump Location

The present results show that fluid challenge with a rapid infusion of 7 mL/kg of saline at right-sided heart catheterization in patients referred for PH helps to discriminate those with postcapillary PH from other types of PH or from control subjects and may reveal hidden PH-LHD in patients undergoing invasive procedures in the catheterization laboratory. A PAWP > 18 mm Hg after fluid challenge allowed reclassification of 6% of patients with precapillary PH and 8% of patients with no PH as having postcapillary PH.

The diagnostic relevance of a fluid challenge depend on the amount of fluid, infusion rate, and cutoff values. Fujimoto et al reported on the hemodynamic responses to rapid infusion of 100 to 200 mL/min of saline up to 2 L in healthy volunteers and in patients with heart failure. In healthy subjects, PAWP increased on average to 16 mm Hg after 1 L and 20 mm Hg after 2 L. In that study, the average slope of PAWP as a function of infused volume was of 6 to 9 mm Hg/L in healthy subjects (lowest in young men, highest in old women) and 13 mm Hg/L in patients with heart failure with preserved ejection fraction (HFpEF). In the present study, the relative increases in PAWP with 7 mL/kg of saline in the control subjects and in the patients with postcapillary PH were of the same magnitude but with a slope increased to 23 mm Hg/L in patients with hidden PH-LHD. Slightly steeper slopes of PAWP as a function of infused volume have been reported in a small study in which the investigators compared the effects of fluid challenge and exercise in 14 patients with HFpEF and in control subjects with no PH with cardiovascular risk factors such as diabetes mellitus, coronary artery disease, and hypertension. Borlaug reanalyzed the data reported by Fujimoto et al and showed that the upper limit of normal for PAWP after rapid infusion of 500 mL of saline would be 18 mm Hg. It is of interest that the exact same upper limit of normal of 18 mm Hg found by Fujimoto et al and Borlaug was confirmed in the present study for the infused amount of 500 mL by rigorously defined quadratic bands. Higher values of PAWP would be reached with larger amounts of fluid loading, as also shown in the present study, but this would not be considered safe in patients with heart failure,,,,, so that standardizing the fluid challenge with more than 500 mL (or 7 mL/kg) would not seem desirable.

Fox et al reported on left-sided and right-sided heart catheterization in 107 patients with scleroderma. Twenty-nine of the patients received a diagnosis of PAH and 24 received a diagnosis of postcapillary PH on the basis of mean PAP and PAWP measurements. Eleven of the patients with PAH then had the diagnosis reclassified as postcapillary on the basis of a left ventricular end-diastolic pressure > 15 mm Hg at baseline (n = 5) or after fluid challenge with 500 mL of saline administered in 5 to 10 min (n = 6). Thus, fluid challenge helped reclassify 22% of the patients otherwise thought to have PAH. Robbins et al showed that 22% of patients with a diagnosis of PAH established by means of right-sided heart catheterization would be reclassified as having postcapillary PH by means of a 500-mL saline challenge-induced increase in PAWP > 15 mm Hg. As previously discussed, this proportion may be excessive. In the present study, decreasing the PAWP threshold to 15 mm Hg increased the number of patients with hidden PH-LHD to eight (12%) among control subjects with no PH and 18 (15%) in patients with precapillary PH. These numbers are not trivial, given the therapeutic relevance and associated costs of correctly categorizing patients referred for PH.,,

It has been suggested recently that exercise might be more sensitive than fluid challenge to detect latent PH-LHD. In that study, exercise compared with rapid volume loading with 150 mL/min of saline up to 10 mL/kg in 14 patients with HFpEF and 12 control subjects led to an almost 2-fold greater increase in PAWP and PAP. However, the study was relatively small, and end-expiratory reading of pulmonary vascular pressures during exercise may have led to an overestimation of PAWP and PAP. Exercise is associated with increased tidal volumes and often also with dynamic hyperinflation, especially in patients with obstructive lung disease who are obese, all increasing PAP and PAWP at end expiration., Thus, at present, whether exercise is preferable to fluid challenge to uncover hidden PH-LHD needs to be tested in larger patient populations and with adequate correction for the influence of exercise-associated intrathoracic pressure and lung volume changes.

There could have been a concern that fluid-challenge-induced increase in PAWP reflected pericardial constraint on ventricular interaction, especially in patients with failing right ventricles and increased RAP. We therefore reanalyzed the results in terms of PAWP-RAP gradients, with the assumption that, as in patients with COPD, RAP would be a satisfactory estimate of intrathoracic pressure or pericardial pressure. The results showed that this gradient increased only in overt or hidden PH-LHD, arguing against a significant effect of pericardial constraint. However, changes in PAWP-RAP did not add to discrimination because the effect size (ie, mean changes with respect to SD) was too small. This is probably explained by variable degrees of right-sided heart failure in PH-LHD.,

The DPG has been introduced for the differential diagnosis between pre- and postcapillary PH.,,, After fluid loading, the DPG decreased in the hidden and in the overt PH-LHD groups but did not change or increase in the other groups. As discussed elsewhere, a decreased DPG after an increased PAWP is likely explained by preserved distensibility of pulmonary resistive vessels and, thus, argues against a diagnosis of pulmonary vascular disease. However, the DPG is a small number, so it is difficult to propose diagnostic cutoff values after a fluid challenge on the basis of the present data.

Fluid challenge in the control subjects with no PH increased RAP by an average of 3 mm Hg to a quadratic band-defined upper limit of 12 mm Hg. The increases in RAP observed in the pre- and postcapillary PH groups were, on average, 5 mm Hg and exceeded 12 mm Hg in most of the patients. There was no discernable cutoff value of RAP after fluid challenge, which in this study allowed discrimination of pre- from postcapillary PH.

A proportion of the patients with PH-LHD had a PVR > 3 Wood units (15 of 22) or a DPG > 7 mm Hg (four of 22), suggesting PH with pulmonary vascular disease added to upstream transmission of pulmonary venous pressure, which currently is defined as “combined pre- and postcapillary PH.”,, The combined pre- and postcapillary PH subtype of PH-LHD defined by a PVR > 3 Wood units and a DPG > 7 mm Hg occurs in approximately 12% to 14% of these patients, and it is associated with a poor prognosis, related to more severe PH and a more rapid deterioration in right ventricular function., In the present study, the prevalence of combined pre- and postcapillary PH in patients with PH-LHD was somewhat higher, with 18% probably explained by selection bias because these patients essentially were referred for workup of PH.

This study has some limitations. The control subjects with no PH were patients with arrhythmias requiring an electrophysiologic study. It could be that perfectly healthy subjects would have a lower PAWP after a 500 mL fluid challenge. However, they showed exactly the same upper limit of normal of 18 mm Hg for PAWP after a fluid challenge of 500 mL, even though it could be argued that the infusion rate of saline (100 to 200 mL/min) was higher in the Fujimoto study compared with in ours. Another limitation is that the patients with LHD had been referred because they were suspected of having severe PH and actually presented with relatively high PVR, TPG, and DPG. Thus, a 6% prevalence of hidden PH-LHD probably would be an overestimation in a population of unselected LHD. Finally, because PAH was overrepresented in the precapillary PH group, it is not possible to know the prevalence of hidden PH-LHD in PH with chronic lung diseases or hypoxia or in CTEPH.

In summary, fluid challenge is a useful adjunct to standard right-sided heart catheterization to detect hidden PH-LHD in patients referred to the catheterization laboratory for a high clinical probability of PH or for invasive procedures. In these patients, the test will allow for a reclassification of 6% to 8% of the patients, which is likely to be of therapeutic relevance.

Author contributions: M. D. takes responsibility for the content of the manuscript, including the data and analysis. M. D. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. M. D. and R. N. contributed to the study design, data analysis and interpretation, and writing of the manuscript. E. R., P. A., A. C., G. M. D. M., A. M. I., R. B., A. D., G. R., B. S., and M. G. R. contributed to data analysis and interpretation. Y. M. contributed to data analysis and interpretation, and the writing of the manuscript.

Financial/nonfinancial disclosures: None declared.

Vachiéry J.L. .Adir Y. .Barberà J.A. .et al Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62:D100-D108 [PubMed]journal. [CrossRef] [PubMed]
 
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Figures

Figure Jump LinkFigure 1 Individual increases in PAWP as a function of volume of rapidly infused saline 7 mL/kg in control subjects with no pulmonary hypertension (PH) (A), patients with precapillary PH (B), and patients with postcapillary PH (C). ● = patients with hidden left-sided heart disease defined by means of a fluid-challenge-induced increase in PAWP > 18 mm Hg. The shaded area corresponds to quadratic fits of the pooled PAWP responses. The horizontal dotted lines correspond to a predefined upper limit of normal of 18 mm Hg for PAWP after fluid challenge. The vertical dotted line corresponds to 500 mL of infused saline. PAWP = pulmonary wedge pressure.Grahic Jump Location
Figure Jump LinkFigure 2 Individual increases in RAP as a function of volume of rapidly infused saline 7 mL/kg in control subjects with no pulmonary hypertension (PH) (A), patients with precapillary PH (B), and patients with postcapillary PH (C). ● = patients with hidden left-sided heart disease defined by means of a fluid-challenge-induced increase in PAWP > 18 mm Hg. The shaded area corresponds to quadratic fits of the pooled RAP responses. The horizontal dotted line corresponds to the upper limit of normal of 12 mm Hg for RAP after fluid challenge. The vertical dotted line corresponds to 500 mL of infused saline. RAP = right atrial pressure. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 3 Boxplots showing increases in PAWP after a rapid infusion of 7 mL/kg saline; these increases were more important in patients with postcapillary PH than in patients with precapillary PH or control subjects with no PH. Six of the eight patients with hidden postcapillary PH from the precapillary PH group were outliers (X). **P < .01 compared with no PH. Δ = change; PH = pulmonary hypertension. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 4 Boxplots showing increases in RAP after a rapid infusion of 7 mL/kg saline; these increases were more important in patients with postcapillary PH or precapillary PH than in control subjects with no PH. Four of the 13 patients with hidden postcapillary PH were outliers (X). **P < .01 compared with no PH. See Figure 2 and 3 legends for expansion of abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Baseline Demographic Characteristics, Comorbidities, and Echocardiographic Findings
a Patients reclassified as having PH due to LHD after a fluid challenge test.
b P < .05 vs no PH.

LHD = left-sided heart disease; LV = left ventricular; PH = pulmonary hypertension.

Table Graphic Jump Location
Table 2 Baseline Hemodynamic Characteristics
a P < .05 vs no PH.

CTEPH = chronic thromboembolic PH; DPG = diastolic pressure gradient; PAH = pulmonary arterial hypertension; PAP = pulmonary artery pressure; PAWP = pulmonary artery wedge pressure; PVR = pulmonary vascular resistance; RAP = right atrial pressure; RV = right ventricular; TPG = transpulmonary pressure gradient; WHO-FC = World Health Organization functional class. See Table 1 legend for expansion of other abbreviations.

Table Graphic Jump Location
Table 3 Hemodynamic Characteristics After Fluid Challenge
a P < .05 vs no PH.

Data are presented as mean ± SD. RA = right atrial. See Table 1 and 2 legends for expansion of other abbreviations.

Table Graphic Jump Location
Table 4 Fluid-Challenge-Induced Changes in Hemodynamic Characteristics
a P < .05 vs no PH.

Data are presented as mean ± SD. Δ = change between before and after fluid challenge. See Table 1 and 2 legends for expansion of other abbreviations.

References

Vachiéry J.L. .Adir Y. .Barberà J.A. .et al Pulmonary hypertension due to left heart diseases. J Am Coll Cardiol. 2013;62:D100-D108 [PubMed]journal. [CrossRef] [PubMed]
 
Galiè N. .Humbert M. .Vachiery J. .et al 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37:67-119 [PubMed]journal. [CrossRef] [PubMed]
 
Rosenkranz S. .Gibbs J.S. .Wachter R. .De Marco T. .Vonk-Noordegraaf A. .Vachiéry J.L. . Left ventricular heart failure and pulmonary hypertension. Eur Heart J. 2016;37:942-954 [PubMed]journal. [CrossRef] [PubMed]
 
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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543