The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction

Ravi Korabathina, Kevin S. Heffernan, Vikram Paruchuri, Ayan R. Patel, James O. Mudd, Jordan M. Prutkin, Nicole M. Orr, Andrew Weintraub, Carey D. Kimmelstiel, Navin K. Kapur

Research output: Contribution to journalArticle

Abstract

Background: Right ventricular dysfunction (RVD) is a major cause of morbidity and mortality in the setting of acute inferior wall myocardial infarction (IWMI), and early detection may improve clinical outcomes. We defined a novel hemodynamic index, the pulmonary artery pulsatility index (PAPi), and explored whether the PAPi correlates with severe RVD in acute IWMI. Methods: From 2008 to 2010, we identified 20 patients presenting with angiographically confirmed proximal right coronary artery occlusion and suspected RVD (sRVD) as defined by hemodynamic instability, profound bradycardia, or ST-elevation in lead V4R. Two controls groups were studied (1) 50 patients with nonobstructive coronary artery disease (Non-CAD) and (2) 14 patients presenting with acute coronary syndrome requiring left coronary stenting (ACS). Hemodynamic indices analyzed at the time of catheterization included: (1) the right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP), (2) right ventricular stroke work (RVSW), and (3) the PAPi. Qualitative echocardiographic scores of RV systolic function were determined by two blinded investigators within 24 hr of catheterization. Results: Among subjects with sRVD, 7 (35%) received a percutaneous RV support device (pRVSD) for medically refractory RV failure and 4 (20%) died prior to hospital discharge. Compared to Non-CAD and ACS controls, subjects with sRVD had a significantly lower PAPi (4.32 ± 3.04 vs. 5.52 ± 4.40 vs. 1.11 ± 0.57, respectively, P <0.01) and a higher RA:PCWP ratio (0.48 ± 0.24 vs. 0.51 ± 0.26 vs. 0.81 ± 0.30, respectively, P <0.05). Both the PAPi and RA:PCWP ratios correlated significantly with RVSW and qualitative echocardiographic grading. The PAPi demonstrated the highest sensitivity (88.9%) and specificity (98.3%) for predicting in-hospital mortality and/or requirement of a pRVSD. Using ROC curve derived cut-points, a PAPi ≤ 0.9 provided 100.0% sensitivity and 98.3% specificity (C-statistic: 0.998) for predicting these outcomes, exceeding the predictive value of the RA:PCWP ratio or RVSW. Conclusions: The PAPi is a simple, invasive hemodynamic measure that may help identify high-risk patients with acute IWMI with severe RVD. Earlier identification of this high-risk population may improve clinical outcomes.

LanguageEnglish (US)
JournalCatheterization and Cardiovascular Interventions
Volume45
Issue number4
DOIs
StateAccepted/In press - 1800
Externally publishedYes

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Right Ventricular Dysfunction
Inferior Wall Myocardial Infarction
Pulmonary Artery
Pulmonary Wedge Pressure
Hemodynamics
Stroke
Catheterization
Coronary Artery Disease
Sensitivity and Specificity
Equipment and Supplies
Acute myocardial infarction
Coronary Occlusion
Acute Coronary Syndrome
Bradycardia
Hospital Mortality
ROC Curve
Coronary Vessels
Research Personnel
Morbidity
Control Groups

Keywords

  • Hemodynamics
  • Myocardial infarction
  • Right ventricle

ASJC Scopus subject areas

  • Pharmacology
  • Drug Discovery
  • Business and International Management
  • Psychology (miscellaneous)
  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

Cite this

Korabathina, R., Heffernan, K. S., Paruchuri, V., Patel, A. R., Mudd, J. O., Prutkin, J. M., ... Kapur, N. K. (Accepted/In press). The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. Catheterization and Cardiovascular Interventions, 45(4). https://doi.org/10.1002/ccd.23309

The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. / Korabathina, Ravi; Heffernan, Kevin S.; Paruchuri, Vikram; Patel, Ayan R.; Mudd, James O.; Prutkin, Jordan M.; Orr, Nicole M.; Weintraub, Andrew; Kimmelstiel, Carey D.; Kapur, Navin K.

In: Catheterization and Cardiovascular Interventions, Vol. 45, No. 4, 1800.

Research output: Contribution to journalArticle

Korabathina, R, Heffernan, KS, Paruchuri, V, Patel, AR, Mudd, JO, Prutkin, JM, Orr, NM, Weintraub, A, Kimmelstiel, CD & Kapur, NK 1800, 'The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction' Catheterization and Cardiovascular Interventions, vol. 45, no. 4. https://doi.org/10.1002/ccd.23309
Korabathina, Ravi ; Heffernan, Kevin S. ; Paruchuri, Vikram ; Patel, Ayan R. ; Mudd, James O. ; Prutkin, Jordan M. ; Orr, Nicole M. ; Weintraub, Andrew ; Kimmelstiel, Carey D. ; Kapur, Navin K. / The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. In: Catheterization and Cardiovascular Interventions. 1800 ; Vol. 45, No. 4.
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T1 - The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction

AU - Korabathina, Ravi

AU - Heffernan, Kevin S.

AU - Paruchuri, Vikram

AU - Patel, Ayan R.

AU - Mudd, James O.

AU - Prutkin, Jordan M.

AU - Orr, Nicole M.

AU - Weintraub, Andrew

AU - Kimmelstiel, Carey D.

AU - Kapur, Navin K.

PY - 1800

Y1 - 1800

N2 - Background: Right ventricular dysfunction (RVD) is a major cause of morbidity and mortality in the setting of acute inferior wall myocardial infarction (IWMI), and early detection may improve clinical outcomes. We defined a novel hemodynamic index, the pulmonary artery pulsatility index (PAPi), and explored whether the PAPi correlates with severe RVD in acute IWMI. Methods: From 2008 to 2010, we identified 20 patients presenting with angiographically confirmed proximal right coronary artery occlusion and suspected RVD (sRVD) as defined by hemodynamic instability, profound bradycardia, or ST-elevation in lead V4R. Two controls groups were studied (1) 50 patients with nonobstructive coronary artery disease (Non-CAD) and (2) 14 patients presenting with acute coronary syndrome requiring left coronary stenting (ACS). Hemodynamic indices analyzed at the time of catheterization included: (1) the right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP), (2) right ventricular stroke work (RVSW), and (3) the PAPi. Qualitative echocardiographic scores of RV systolic function were determined by two blinded investigators within 24 hr of catheterization. Results: Among subjects with sRVD, 7 (35%) received a percutaneous RV support device (pRVSD) for medically refractory RV failure and 4 (20%) died prior to hospital discharge. Compared to Non-CAD and ACS controls, subjects with sRVD had a significantly lower PAPi (4.32 ± 3.04 vs. 5.52 ± 4.40 vs. 1.11 ± 0.57, respectively, P <0.01) and a higher RA:PCWP ratio (0.48 ± 0.24 vs. 0.51 ± 0.26 vs. 0.81 ± 0.30, respectively, P <0.05). Both the PAPi and RA:PCWP ratios correlated significantly with RVSW and qualitative echocardiographic grading. The PAPi demonstrated the highest sensitivity (88.9%) and specificity (98.3%) for predicting in-hospital mortality and/or requirement of a pRVSD. Using ROC curve derived cut-points, a PAPi ≤ 0.9 provided 100.0% sensitivity and 98.3% specificity (C-statistic: 0.998) for predicting these outcomes, exceeding the predictive value of the RA:PCWP ratio or RVSW. Conclusions: The PAPi is a simple, invasive hemodynamic measure that may help identify high-risk patients with acute IWMI with severe RVD. Earlier identification of this high-risk population may improve clinical outcomes.

AB - Background: Right ventricular dysfunction (RVD) is a major cause of morbidity and mortality in the setting of acute inferior wall myocardial infarction (IWMI), and early detection may improve clinical outcomes. We defined a novel hemodynamic index, the pulmonary artery pulsatility index (PAPi), and explored whether the PAPi correlates with severe RVD in acute IWMI. Methods: From 2008 to 2010, we identified 20 patients presenting with angiographically confirmed proximal right coronary artery occlusion and suspected RVD (sRVD) as defined by hemodynamic instability, profound bradycardia, or ST-elevation in lead V4R. Two controls groups were studied (1) 50 patients with nonobstructive coronary artery disease (Non-CAD) and (2) 14 patients presenting with acute coronary syndrome requiring left coronary stenting (ACS). Hemodynamic indices analyzed at the time of catheterization included: (1) the right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP), (2) right ventricular stroke work (RVSW), and (3) the PAPi. Qualitative echocardiographic scores of RV systolic function were determined by two blinded investigators within 24 hr of catheterization. Results: Among subjects with sRVD, 7 (35%) received a percutaneous RV support device (pRVSD) for medically refractory RV failure and 4 (20%) died prior to hospital discharge. Compared to Non-CAD and ACS controls, subjects with sRVD had a significantly lower PAPi (4.32 ± 3.04 vs. 5.52 ± 4.40 vs. 1.11 ± 0.57, respectively, P <0.01) and a higher RA:PCWP ratio (0.48 ± 0.24 vs. 0.51 ± 0.26 vs. 0.81 ± 0.30, respectively, P <0.05). Both the PAPi and RA:PCWP ratios correlated significantly with RVSW and qualitative echocardiographic grading. The PAPi demonstrated the highest sensitivity (88.9%) and specificity (98.3%) for predicting in-hospital mortality and/or requirement of a pRVSD. Using ROC curve derived cut-points, a PAPi ≤ 0.9 provided 100.0% sensitivity and 98.3% specificity (C-statistic: 0.998) for predicting these outcomes, exceeding the predictive value of the RA:PCWP ratio or RVSW. Conclusions: The PAPi is a simple, invasive hemodynamic measure that may help identify high-risk patients with acute IWMI with severe RVD. Earlier identification of this high-risk population may improve clinical outcomes.

KW - Hemodynamics

KW - Myocardial infarction

KW - Right ventricle

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