Figure 1
Flow diagram showing the selection of study cohort.
* Cases with absent clinical data or electrocardiogram.
** Patients with transient elevated PASP due to acute respiratory infections, acute respiratory distress syndrome and positive pressure mechanical ventilation.
Table 1
Baseline Demographic and Clinical Characteristics.
| All patients N = 659 | |
|---|---|
| Demographics | |
| Age (years) | 65.72 ± 17.45 |
| Gender, n (%) | |
| Females | 363 (55.1) |
| Males | 296 (44.9) |
| Race | |
| Blacks, n (%) | 527 (80.0) |
| Non-Blacks, n (%) | 132 (20.0) |
| Comorbidities | |
| Systemic Arterial Hypertension, n (%) | 459 (69.7) |
| Diabetes Mellitus, n (%) | 224 (34.0) |
| Smoking, n (%) | 66 (10.0) |
| Heart failure, n (%) | 344 (52.2) |
| COPD, n (%) | 78 (11.8) |
| HIV, n (%) N = 206 | 28 (13.6) |
| Systolic BP (mmHg), median (IQR) | 82 (72–94) |
| Systolic BP (mmHg), median (IQR) | 129 (111–147) |
| Weight (kg) | 76.23 ± 18.82 |
| Body Mass Index, median (IQR) | 28 (24–32) |
| Underweight, BMI < 18.5 | 22 (3.3%) |
| Normal, BMI 18.5–24.9 | 161 (24.4%) |
| Overweight, BMI 25.0–29.9 | 235 (35.7%) |
| Stage I obesity, BMI 30.0–34.9 | 136 (20.6%) |
| Stage II obesity, BMI 35.0–39.9 | 59 (9%) |
| Extreme Obesity, BMI ≥ 40.0 | 43 (6.5%) |
| WHO functional class, n (%) | |
| Class I/II | 192 (43.5) |
| Class III/V | 249 (56.5) |
[i] * Plus-minus values are means ± SD.
IQR, interquartile range; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; BP, blood pressure; WHO, world health organization.
Table 2
Electrocardiographic and Echocardiographic findings.
| All patients (N = 650) | |
|---|---|
| Electrocardiographic findings | |
| Atrial Fibrillation, n (%) | 99 (15.0) |
| Echocardiographic findings | |
| TRV (ms), median (IQR) | 3.42 (3.22–3.79) |
| RAP (mmHg) | 9.60 ± 5.28 |
| PASP (mmHg), median (IQR) | 56 (49–68) |
| TAPSE (mm) (N = 580), median (IQR) | 18 (15–20) |
| LVEF (%), median (IQR) | 55 (38–60) |
| LVEF < 40% | 186 (28.2) |
| Congenital Heart Disease, n (%) | 38 (5.8) |
| Significant valvular abnormalities, n (%) | 189 (28.7) |
| Rheumatic valvular changes, n (%) | 37 (5.6) |
[i] * Plus-minus values are means ± SD.
IQR, interquartile range; TRV, tricuspid regurgitant velocity; RAP, right atrial pressure; PASP, pulmonary artery systolic pressure; TAPSE, tricuspid annular plane systolic excursion; LVEF, left ventricular ejection fraction.
Figure 2
WHO groups of pulmonary hypertension assigned by primary physician.
PAH: pulmonary arterial hypertension; PH-LHD: PH due to left heart disease; PH-LD: PH due to lung disease; CTEPH: chronic thromboembolic PH.
Table 3
Sub-group classification of pulmonary hypertension.
| Total (N = 546) | % | |
|---|---|---|
| Group 1 | 72 | |
| Congenital heart disease | 31 | 5.7% |
| HIV associated PAH | 18 | 3.3% |
| Connective tissue disease | 15 | 2.7% |
| Idiopathic PAH | 6 | 1.1% |
| Portal hypertension | 2 | 0.4% |
| Group 2 | 318 | |
| HFrEF | 164 | 30.0% |
| HFpEF | 85 | 15.6% |
| Rheumatic valvular heart disease | 36 | 6.6% |
| Other valvular heart diseases | 31 | 5.6% |
| Others | 2 | 0.4% |
| Group 3 | 122 | |
| COPD | 63 | 11.5% |
| Sleep disordered breathing | 23 | 4.2% |
| Interstitial lung disease | 13 | 2.4% |
| Post TB bronchiectasis | 7 | 1.3% |
| Others | 14 | 2.89% |
| Group 4 | 28 | 5.1% |
| Group 5 | 8 | |
| Sickle cell disease | 4 | 0.7% |
| Others | 4 | 0.7% |
[i] PAH, pulmonary arterial hypertension; HFrEF, heart failure with reduced ejection fraction; COPD, chronic obstructive pulmonary disease; HFpEF, heart failure with preserved ejection fraction; TB, tuberculosis. Of the congenital heart disease 16 had ASD, 1 PDA, 1 VSD, 4 Tetralogy of Fallot and 9 others.
Figure 3
Kaplan-Meier survival estimates for (A) Overall cohort; (B) by WHO functional class; (C) by BMI; (D) by severity of PASP; (E) by LVEF and (F) by TAPSE.
WHO, World Health Organization; BMI, Body Mass Index; PH, pulmonary hypertension; PASP, pulmonary artery systolic pressures; LVEF, left ventricular ejection fraction; LV, left ventricular; RV, right ventricular; TAPSE, tricuspid annular plane systolic excursion.
Table 4
Two-year survival rates.
| Probability of survival (%) | |
|---|---|
| 6 months | 78.9 ± 1.6 |
| 1 year | 73.8 ± 1.8 |
| 2 years | 65.9 ± 2.1 |
[i] * Plus-minus values are overall survival rate ± SE.
Table 5
Cox regression analysis.
| Univariate Analysis¶ | Multivariate Analysis¥ | |||
|---|---|---|---|---|
| Unadjusted HR ± 95% CI | p-value | Adjusted HR ± 95% CI | p-value | |
| Age | 1.03 (1.02–1.04) | <0.001 | 1.02 (1.01–1.03) | <0.001 |
| Male Gender | 1.23 (0.93–1.63) | 0.14 | 1.17 (0.88–1.54) | 0.29 |
| Systemic Arterial Hypertension | 1.12 (0.82–1.54) | 0.50 | 0.73 (0.52–1.02) | 0.07 |
| Diabetes Mellitus | 1.61 (1.22–2.14) | 0.001 | 1.49 (1.13–1.98) | 0.005 |
| Obesity (BMI ≥ 30) | 0.68 (0.50–0.93) | 0.01 | 0.66 (0.48–0.90) | 0.01 |
| WHO Class III/IV | 3.53 (2.49–5.00) | <0.001 | 3.50 (2.47–4.97) | <0.001 |
| Atrial Fibrillation | 1.72 (1.22–2.42) | 0.001 | 1.53 (1.07–2.17) | 0.02 |
| Severe PH (PASP ≥ 60) | 1.68 (1.27–2.22) | <0.001 | 1.68 (1.27–2.22) | <0.001 |
| RV dysfunction (TAPSE < 17 mm) | 2.58 (1.92–3.48) | <0.001 | 2.61 (1.93–3.53) | <0.001 |
| LV dysfunction (LVEF ≤ 40%) | 2.15 (1.62–2.85) | <0.001 | 2.18 (1.64–2.91) | <0.001 |
| Significant valvular heart disease | 1.44 (1.07–1.93) | 0.02 | 1.28 (0.93–1.76) | 0.13 |
| Rheumatic heart disease | 0.54 (0.24–1.21) | 0.13 | 1.19 (0.50–2.80) | 0.70 |
[i] ¶ Cox regression performed after confirmation of proportional hazard assumptions using log minus log graphs.
¥ A multivariate cox regression model adjusted for confounders (age, gender, race and presence of diabetes mellitus).
* P < 0.05 was considered significant.
BMI, body mass index; WHO, world health organization; PH, pulmonary hypertension; RV, right ventricle; LV, left ventricle; TAPSE, tricuspid annular plane systolic excursion; LVEF, left ventricular ejection fraction.
Interactions for Obesity and Age, Obesity and DM, and Obesity and Gender were performed and no interactions were present.