In hospital major adverse cardiovascular events in acute heart failure: prognostic role of echocardiographic pulmonary hypertension probability

Abstract

Background: Pulmonary hypertension secondary to left heart disease (PH-LHD) is predominant type of pulmonary hypertension observed in hospitalized acute heart failure (AHF) patients. Bedside echocardiography for AHF patients offers a pragmatic approach for assessing probability of pulmonary hypertension (PH); however, data correlating the probability of PH as determined by echocardiography to in hospital major adverse cardiovascular events (MACE) throughout hospitalization remain limited. Methods: This retrospective cohort study was undertaken at a single location, gathered data from the AHF registry at Saiful Anwar General Hospital in Malang, Indonesia, from January 2024 to December 2025. Adult patients admitted for acute heart failure who had transthoracic echocardiography (TTE) within 24 hours of arrival were incorporated into study. The probabilities of pulmonary hypertension, assessed via echocardiography, has been classified as low, moderate, or high in accordance with the 2022 ESC/ERS criteria. The principal outcome was in hospital MACE, characterized as in hospital mortality, cardiac arrest necessitating resuscitation, and/or cardiogenic shock needing medicinal or mechanical hemodynamic intervention. A hierarchical multivariate logistic regression analysis was conducted, controlling for age, sex, body mass index (BMI), Killip, left ventricular ejection fraction (LVEF), utilization of mineralocorticoid receptor antagonists (MRA), and angiotensin receptor-neprilysin inhibitor (ARNI) medication. Result: A total of 403 patients (median age 61 years; 56.6% male) were enrolled in study, with in-hospital MACE occurring in 124 patients (30.8%). The MACE rate increased in parallel with the increase in PH probability categories: 25.7% (Low), 30.4% (Moderate), and 48.0% (High; p < 0.001). Multivariate analysis demonstrated that elevated PH probability was an independent predictor of in hospital MACE across all three hierarchical models (Model 1: OR 2.91, 95% CI 1.67–5.07; Model 2: OR 2.84, 95% CI 1.63–4.95; Model 3: OR 2.97, 95% CI 1.66–5.32; all p < 0.001), even after full adjustment for LVEF and therapy. Killip class was an independent predictor in all models (OR 1.51–1.77). Therapy use: Beta Blocker (BB) (OR 0.54), MRA (OR 0.43), and ARNI (OR 0.19) each independently reduced the risk of MACE. The resultant model exhibited satisfactory discrimination (AUC 0.73, 95% CI 0.68–0.78) and robust calibration (Hosmer Lemeshow p = 0.41. Conclusion: A high probability of PH assessed using echocardiography can detect high-risk AHF and independently forecast MACE during hospitalization, irrespective of LVEF, clinical severity, and treatment modalities. These findings support the use of echocardiography-based PH probability for early bedside risk determination in hospitalized AHF patient. Keyword : Acute Heart Failure; Echocardiography; Left Heart Disease; Major Adverse Cardiovascular Events; Pulmonary Hypertension.