Characteristics and prognosis of patients with decompensated right ventricular failure during the course of pulmonary hypertension.

BACKGROUND: New therapies for pulmonary arterial hypertension have prolonged survival but simultaneously increased the number of hospital admissions because of decompensated right heart failure (DRHF). The optimal approach in DRHF has not been established yet.

AIM: Analysis of clinical course of DRHF in a group of patients with pulmonary hypertension treated in a single referral centre.

METHODS: We retrospectively analysed 60 episodes of DRHF in 37 patients (29 females, mean age 44+/-17 years) with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension admitted to our hospital between 2005 and 2007. We assessed the cause of decompensation, vital signs at admission, functional class and laboratory values. We classified all episodes into four haemodynamic profiles using the value of systolic blood pressure together with presence of peripheral perfusion abnormalities (profile cold vs. warm) and symptoms of venous congestion (profile wet vs. dry). Primary end-point was in-hospital mortality.

RESULTS: The most common causes of DRHF were infection (27%), drug noncompliance (20%), and pulmonary embolism (3%). In 48% no causative factor was indentified. There were 19 (32%) in-hospital deaths. The highest mortality was observed among patients with connective tissue disease (61%). The haemodynamic profile 'warm-wet' was the most common (48%) and the profile 'cold-dry' was the rarest but was associated with a 100% mortality. Patients who died had higher value of functional class (3.84+/-0.38 vs. 3.51+/-0.55, p=0.01) and higher activity of aspartate transaminase (61+/-61 vs. 42+/-78 U/l, p=0.02) compared with those who survived. In multivariate analysis higher dopamine dose (RR 2.0/1 microg/kg/min, 95% CI 1.00-5.00, p <0.001) was an independent factor of in-hospital death. In contrast 'rescue therapy' with iloprost or treprostinil decreased mortality (RR 0.09, 95% CI 0.01-0.99, p=0.04). Mortality in patients receiving dopamine was higher (60 vs. 18%, p=0.001) than in patients treated without dopamine.

CONCLUSION: Mortality in patients with pulmonary hypertension and DRHF remains very high and seems to be related to haemodynamic profile on admission. The newly introduced therapy with parenteral prostanoids may be more beneficial than dopamine infusion.