Pulmonary Hypertension in Heart Failure: Is the Prognostic Impact Changing?

Background: Pulmonary hypertension (PH) is a key prognostic marker in heart failure (HF), yet its management remains challenging, particularly in elderly populations. This study evaluates trends in mortality among HF patients and examines how the prognostic impact of PH has evolved over more than a decade.

Methods: A retrospective analysis of HF patients treated from 2009 up to December 2024 in a single tertiary center, both ambulatory and hospitalized. Kaplan-Meier survival analysis and Cox proportional hazards regression models were applied, stratifying patients by PH (defined as estimated systolic pulmonary artery pressure ≥40 mmHg) and time period (before and after June 2016).

Results: The final cohort included 32,902 patients (median age 72 years [IQR 64–82 ]), 19,168 (58%) males, of whom 14,627 (44%) had PH (median SPAP 44 mmHg [IQR 33–52]). Over a median follow-up of 5 years (IQR 1–7), 18,558 (56%) patients died. During the study period treatment strategies evolved significantly incorporating more sodium glucose cotransporter inhibitors-2 (12% vs. 1.4%), mineralocorticoid receptor antagonist (26% vs. 6%) and angiotensin receptor/neprilysin inhibitor (11.5% vs. 3.5%). Overall in the entire cohort, compared with no PH, PH patients were 40% more likely to die during follow-up (95% CI 1.29–1.52, p < 0.001). Interaction analysis demonstrated that PH-associated mortality risk was period-dependent, such that it was more pronounced in the early compared with the late time period (HR1.4, 95% CI 1.28-1.52 vs. 1.15 95% 1.02-1.31, p for interaction = 0.015).

Conclusions: PH remains a significant predictor of mortality in contemporary HF patients. However, its impact has attenuated in recent years, potentially reflecting the adoption of guideline-directed medical therapy. These findings highlight the need for continued innovation in HF management to further improve outcomes for patients with PH.