Prognostic Implications of High HFpEF Probability in Patients With Chronic Thromboembolic Pulmonary Hypertension

Abstract

ABSTRACT Background Chronic thromboembolic pulmonary hypertension (CTEPH) and left heart disease, particularly heart failure with preserved ejection fraction (HFpEF), show overlapping clinical features despite distinct pathophysiology. Objectives The HFpEF‐ABA algorithm (age, body mass index, atrial fibrillation) was used to characterize HFpEF pretest probability in patients with CTEPH and evaluate its association with left heart disease and clinical worsening. Methods Among 466 patients with CTEPH stratified by HFpEF‐ABA score (low < 25%, intermediate 25%–74%, high ≥ 75%), Spearman's correlation assessed associations with common left heart disease comorbidities. Kaplan‐Meier analysis and Cox regression evaluated associations with clinical worsening, with restricted cubic splines assessing the dose‐response relationship and non‐linearity. Subgroup analyses by sex, smoking, alcohol use, hypertension, coronary artery disease, and obstructive sleep apnea assessed the consistency. We also evaluated whether adding the HFpEF‐ABA score improved COMPERA 2.0 discrimination for clinical worsening. Results Intermediate and high HFpEF probability was found in 52.4% (n = 244) and 9.0% (n = 42), respectively. After adjustment, each standard deviation increase in HFpEF probability was associated with an approximately 73% increase in clinical worsening (p < 0.001). Results were consistent for HFpEF probability (p < 0.05), with no significant subgroup interactions. Adding HFpEF‐ABA with COMPERA 2.0 improved discrimination, increasing the C‐index increasing from 0.532 to 0.634 (p = 0.012). Conclusions Assessing HFpEF probability in patients with CTEPH identifies those at high risk for this comorbidity and improves the precision when integrated with existing risk models.