Echocardiographic risk stratification in heart failure with post-capillary pulmonary hypertension: prognostic value of LAVI and TAPSE/PASP

AIMS: Post-capillary pulmonary hypertension (pcPH) is a frequent complication of heart failure (HF), associated with poor outcomes. While right heart catheterization (RHC) is the diagnostic gold standard, echocardiographic indices such as left atrial volume index (LAVI) and the TAPSE/PASP ratio may offer non-invasive prognostic value. OBJECTIVES: To assess the prognostic utility of LAVI and TAPSE/PASP compared with invasive haemodynamic parameters in patients with HF and pcPH undergoing RHC. METHODS AND RESULTS: The PH-HF study is a prospective multicentre cohort of adults with chronic HF and confirmed pcPH (mPAP > 20 mmHg and pulmonary arterial wedge pressure > 15 mmHg) enrolled across 13 French centres (2012-2018). Patients with precapillary PH or severe pulmonary/renal comorbidities were excluded. The primary outcome was a 3-year composite of all-cause mortality, urgent heart transplantation or LVAD, or unplanned HF hospitalization. Cox regression was used for survival analyses. Overall, 55% of patients met the composite echocardiographic risk criterion (LAVI > 35 mL/m² or TAPSE/PASP < 0.40), which was associated with increased risk of adverse events (HR 1.97, 95% CI 1.41-2.75; P < 0.0001). Results were consistent across HFrEF and HFpEF phenotypes. In a multivariable model including the MAGGIC score, both the echocardiographic criterion and the clinical score remained independently associated with outcomes, supporting their complementary value in risk stratification. CONCLUSION: LAVI and TAPSE/PASP are strong, non-invasive predictors of adverse outcomes in HF with pcPH and may enhance prognostic assessment beyond invasive haemodynamics and clinical scores.