Prominent V waves in HFpEF inflate the apparent pulmonary vascular disease

Design

Retrospective cohort with invasive exercise haemodynamics

Population

1,069 patients with HFpEF and less than moderate mitral regurgitation

Primary outcome

Haemodynamic, echocardiographic and clinical differences by V wave status; HF hospitalisation or death

Effect

Combined pre- and post-capillary PH 60.2% → 29.3% after V wave correction; adjusted HR 2.09 (1.53–2.86) for HF hospitalisation or death

This retrospective cohort included 1,069 patients with heart failure with preserved ejection fraction (HFpEF) and less than moderate mitral regurgitation who underwent invasive exercise haemodynamics. A prominent V wave was defined as a wedge V wave at least 10 mm Hg above mean wedge pressure; 225 patients (21%) had one.

These patients had a larger, stiffer left atrium (LA volume index 42.2 vs 32.5 mL/m², reservoir strain 16.4% vs 23.2%) and far more atrial fibrillation (61.3% vs 22.9%). Pulmonary artery systolic pressure was 54 vs 38 mm Hg, yet the end-diastolic wedge-to-PA gradient was identical. Once the wedge pressure was corrected for the V wave, the share labelled combined pre- and post-capillary pulmonary hypertension fell from 60.2% to 29.3%. Pulmonary artery compliance was much lower (3.03 vs 4.90 mL/mm Hg), right ventricular function and tricuspid regurgitation were worse, and the adjusted hazard of heart failure hospitalisation or death was 2.09.

The practical point is twofold. A stiff atrium can load the right ventricle without any pulmonary vascular disease, and reading the mid-A wave wedge alone can misclassify these patients as having combined pulmonary hypertension — a label that can lead towards pulmonary vasodilators that are not indicated.

• When reviewing a right heart catheter report in HFpEF, look at the size of the wedge V wave, not just the mean.
• A wedge V wave 10 mm Hg or more above mean wedge flags a stiff left atrium, even without significant mitral regurgitation.
• Be cautious about labelling combined pre- and post-capillary pulmonary hypertension when a large V wave is present.
• Atrial fibrillation and a large, poorly compliant left atrium make a prominent V wave more likely.
• Patients with this pattern had more right ventricular dysfunction and twice the risk of hospitalisation or death.

Why it matters

It shows that left atrial stiffness alone can strain the right heart, and that standard wedge readings can mislabel these patients.

Don't overread it

This is a retrospective cohort — it does not show that treating the atrium improves outcomes.

The statistics, in plain English

The adjusted hazard ratio of 2.09 (95% CI 1.53–2.86) means about double the rate of heart failure hospitalisation or death after accounting for other measured differences; the whole interval sits well above 1. The R² comparison (0.96 vs 0.86) shows the V wave-corrected wedge tracked the true average wedge pressure more closely.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.