Discharge pulmonary artery pulsatility index predicts morbidity and mortality after acute heart failure: From the ESCAPE trial

Abstract

Introduction: The pulmonary artery pulsatility index (PAPI) is a newer hemodynamic index used for assessment of right ventricular performance. We hypothesized that PAPI predicts morbidity and mortality in acute systolic heart failure (HF). Methods: The ESCAPE trial was utilized to identify the prognostic value of PAPI at different time points in patients hospitalized with acute systolic HF who received care assisted with central hemodynamic monitoring. Results: Among 167 patients (age 57 years, 71% men), PAPI significantly increased from admission to optimum hemodynamic day (from 2.88 to 4.09, P < 0.001) and final day (from 3.24 to 3.91, P = 0.032), and the magnitude of increase was strongly associated with markers of decongestion. Discharge PAPI was higher among survivors compared to non-survivors (median 3.1 vs. 2.0, P=0.0008) and among patients who did not require rehospitalization compared to re-hospitalized patients (median 3.33 vs. 2.67, P=0.017), both at 6-months. Discharge PAPI predicted mortality with AUC of 0.631 (P= 0.0207), rehospitalization (AUC 0.598, P = 0.0303), and composite of death, rehospitalization, cardiac transplant (AUC 0.621, P = 0.0101). An optimal cutoff value of discharge PAPI≤2 had the highest sensitivity and specificity in predicting 6-month mortality, rehospitalization and the composite endpoint. Discharge PAPI, had a higher (though non-significant) AUC in predicting death and composite endpoint compared to admission PAPI, next day PAPI and optimal day PAPI. Cox proportional hazard analysis showed that discharge PAPI remained an independent predictor of the composite endpoint (hazard ratio 0.890, 95% CI 0.819–0.967, P = 0.006) after covariate adjustment. Conclusions: Discharge PAPI≤2 is a marker of intermediate-term morbidity and mortality in acute systolic HF.