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: Research - peer-reviewArticle

    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

    Fingerprint

    Right Ventricular Dysfunction
    Inferior Wall Myocardial Infarction
    Pulmonary Artery
    Acute myocardial infarction
    Pulmonary Wedge Pressure
    Hemodynamics
    Stroke
    Myocardial infarction
    Catheterization
    Coronary Artery Disease
    Sensitivity and Specificity
    Equipment and Supplies
    Specificity
    Coronary artery disease
    Mortality
    Coronary Occlusion
    Acute Coronary Syndrome
    Bradycardia
    Hospital Mortality
    ROC Curve

    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

    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: Research - peer-reviewArticle

    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. DOI: 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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    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.",
    keywords = "Hemodynamics, Myocardial infarction, Right ventricle",
    author = "Ravi Korabathina and Heffernan, {Kevin S.} and Vikram Paruchuri and Patel, {Ayan R.} and Mudd, {James O.} and Prutkin, {Jordan M.} and Orr, {Nicole M.} and Andrew Weintraub and Kimmelstiel, {Carey D.} and Kapur, {Navin K.}",
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    TY - JOUR

    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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    DO - 10.1002/ccd.23309

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    SN - 1522-1946

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