European Journal of Cardiovascular Medicine

Heart failure is a progressive clinical syndrome affecting millions worldwide and is characterized by structural and functional abnormalities of the heart, leading to impaired ventricular function^[1]. HF is classified into three major categories based on LVEF: heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF)^[2]. While echocardiography is the gold standard for evaluating LVEF, there is increasing interest in non-invasive markers such as proportional pulse pressure (PPP) to provide additional insight into HF severity.^[3]

Proportional pulse pressure is calculated as the ratio of pulse pressure to systolic blood pressure and reflects arterial stiffness, vascular compliance, and overall cardiac function.^[4] Studies have shown that a lower PPP is associated with increased HF severity and adverse cardiovascular outcomes.^[5] PPP has the advantage of being an easily measurable, cost-effective marker that could supplement conventional HF assessment methods.^[6]

The pathophysiology of heart failure involves a complex interplay of neurohormonal activation, ventricular remodeling, and hemodynamic changes, all of which contribute to alterations in arterial stiffness and pulse pressure ^[7]. Given these changes, PPP has been proposed as a potential surrogate marker for HF severity. This study aims to evaluate the correlation between PPP and HF severity, using LVEF as a reference parameter, and determine whether PPP can serve as a clinically valuable tool in HF assessment.^[8]

Study Design

This cross-sectional study was conducted at a tertiary care hospital to assess patients diagnosed with heart failure (HF). The study aimed to evaluate patients based on their left ventricular ejection fraction (LVEF) and classify them into specific HF subtypes.

Objective of the study was to determine association of proportional pulse pressure with grades of left ventricular ejection fraction in heart failure patients.

Study Duration: January 2023 and June 2024.

Study Population and Sample Size

A total of 92 patients diagnosed with HF were included in the study. Participants were categorized into three groups according to their LVEF:

• Heart failure with reduced ejection fraction (HFrEF): LVEF ≤ 40%
• Heart failure with mildly reduced ejection fraction (HFmrEF): LVEF 41–49%
• Heart failure with preserved ejection fraction (HFpEF): LVEF ≥ 50%

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Adult patients (≥ 18 years) diagnosed with HF
• Patients with available echocardiographic data for LVEF classification

Exclusion Criteria:

• Patients with incomplete medical records
• Presence of significant valvular heart disease or congenital heart defects

Measurement of Proportional Pulse Pressure (PPP)

Proportional pulse pressure is pulse pressure divided by systolic blood pressure. PPP was calculated as follows: where Pulse Pressure (PP) is the difference between systolic and diastolic blood pressure. Proportional Pulse Pressure is calculated by dividing Pulse Pressure by Systolic Blood Pressure (PPP = PP / SBP). PPP was measured using a standard sphygmomanometer and calculated using blood pressure readings taken in a seated position after five minutes of rest.

Data Collection and Analysis

Data on patient demographics, medical history, NYHA classification, and echocardiographic findings were collected. Statistical analysis included correlation coefficients and regression models to assess the relationship between PPP and LVEF. Significance was set at p < 0.05.

A significant inverse correlation was observed between PPP and HF severity. The chi-square test yielded a significant association (χ² = 6.67, p = 0.03), indicating that patients with PPP ≤ 25% were more likely to have HFrEF. Conversely, higher PPP values were associated with better-preserved LVEF.

Table 1: Hemodynamic and Clinical Parameters Across HF Categories

Table 1 presents the hemodynamic and clinical parameters across different heart failure (HF) categories based on left ventricular ejection fraction (LVEF):

• Pulse Pressure Percentage (PPP): Increases from 23% in HFrEF to 38% in HFpEF, suggesting differences in vascular compliance.
• LVEF: As expected, the mean LVEF is lowest in HFrEF (33%) and highest in HFpEF (57%).
• NT-proBNP Levels: A biomarker for HF severity, NT-proBNP is highest in HFrEF (3500 pg/mL) and lowest in HFpEF (800 pg/mL).
• NYHA Class III-IV Patients: Higher in HFrEF (76%), indicating a greater functional limitation compared to HFpEF (18%).

Table 2: Finding the Association of LVEF with PPP in Study Participants (n=92)

Table 2 examines the association between LVEF and pulse pressure percentage (PPP) among the 92 study participants. Key findings include:

• A significant association (p = 0.03) between LVEF and PPP, as determined by the Chi-square test.
• The majority of patients with LVEF ≤ 40% (HFrEF) had PPP ≤ 25% (41 out of 53).
• In contrast, patients with LVEF ≥ 50% (HFpEF) were more evenly distributed between PPP ≤ 25% (12 patients) and > 25% (8 patients).
• Only 1 participant in the HFmrEF group had PPP > 25%, suggesting a distinct pattern in this subgroup.

The findings suggest a potential relationship between lower PPP and reduced LVEF, which may have implications for HF severity and vascular function.

Table 3: Prevalence of Clinical Comorbidities in HF Patients

This table illustrates the prevalence of common comorbid conditions such as hypertension, diabetes mellitus, and coronary artery disease among HF patients, categorized by LVEF group.

Figure 1

Our findings align with prior research indicating that reduced PPP correlates with worsening cardiac function.^[9] Lower PPP reflects compromised arterial compliance and decreased stroke volume, both hallmarks of HFrEF. Patients with higher PPP values had preserved LVEF, consistent with HFpEF pathophysiology.^[10] This suggests that PPP could serve as an effective marker for distinguishing HF phenotypes.^[11]

demonstrated that PPP serves as an independent predictor of mortality in HF patients, reinforcing its clinical relevance. Additionally, highlighted that PPP correlates strongly with systemic vascular resistance and left ventricular end-diastolic pressure.^[12] These findings underscore the importance of PPP as a hemodynamic parameter in HF evaluation. However, further studies with larger cohorts and long-term follow-up are needed to validate its predictive accuracy.^[13]

In our study, narrow proportional pulse pressure (PPP) shows a positive correlation with heart failure with reduced ejection fraction (HFrEF). Patients with a narrow PPP are more likely to have heart failure with reduced ejection fraction. The severity of reduced ejection fraction (EF) is proportionally related to decreasing PPP values. Given that narrow PPP is linked to heart failure with reduced EF, it may serve as a predictor of poorer outcomes for such patients. This emphasizes the importance of providing closer monitoring and tailored treatment strategies for individuals with lower PPP. Applying PPP as a routine clinical measure in all heart failure patients could help differentiate between those with heart failure with reduced ejection fraction (HFrEF) and those with preserved ejection fraction (HFpEF), aiding in more accurate prognosis and treatment planning.

LIMITATIONS OF THE STUDY

• Single-center study with a limited sample size.
• Lack of long-term follow-up data.
• Potential confounders such as medication effects were not extensively analyzed.

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