Prognostic role of invasively determined pulmonary hypertension in ambulatory patients with advanced heart failure: a prospective cohort study

Background: Pulmonary hypertension (PH) complicates advanced heart failure (AdvHF) and may limit access to life-saving therapies such as heart transplantation (HTx). However, the independent prognostic weight of PH in contemporary cohorts of AdHF patients remains unclear. Methods: We prospectively enrolled ambulatory patients with AdvHF referred to a tertiary center for evaluation of advanced therapies. All patients were on guideline-directed medical therapy (GDMT) and underwent a comprehensive assessment, including cardiopulmonary exercise testing, echocardiography, and right heart catheterization (RHC). PH was defined as a mean pulmonary pressure >= 20 mmHg at RHC. The primary endpoint was a composite of all-cause death/left ventricular assist device implantation/HTx. Results: Among 149 patients (mean age 53 +/- 12 years, 75% male; on four-drug GDMT 75.2%), 70 (47%) had PH at baseline. During follow-up, 44 patients (29.5%) experienced the primary endpoint, with a higher event rate in the PH group (38.6% vs 21.5%). In multivariable Cox analysis, PH remained the only independent predictor of the composite endpoint (HR 3.46, 95% CI 1.08-11.05; p = 0.037).Conclusion: In ambulatory patients with AdvHF referred for advanced therapies, invasively confirmed PH is an independent prognostic determinant. Systematic assessment of PH should be integrated into risk stratification to optimize the timing of referral to advanced therapies.