Combined Assessment of Pulmonary Artery Pulsatility Index and Compliance for Risk Stratification in Advanced Heart Failure: A Post-hoc Analysis of the ESCAPE Trial

Background In advanced heart failure (HF), dynamic interplays between right ventricular (RV) dysfunction and afterload complicate prognostic assessments. The pulmonary artery pulsatility index (PAPi) reflects RV function, while pulmonary arterial capacitance (PAC) represents the pulsatile component of afterload. We investigated whether a combined PAPi-PAC assessment improves risk stratification in patients with decompensated advanced HF. Methods This retrospective analysis included 187 patients with advanced HF and complete baseline PAPi and PAC data from the ESCAPE trial. The composite endpoint included all-cause death, left ventricular assist device implantation, or orthotopic heart transplantation within 6 months. A grid search approach identified optimal cutoffs for PAPi (2.00) and PAC (1.64), stratifying patients into four groups. Results In Cox models adjusted for the Get With The Guidelines-Heart Failure (GWTG-HF) score, the low PAPi/low PAC group had the highest risk of the composite endpoint compared with the high PAPi/high PAC group (hazard ratio [HR] 3.167, 95% confidence interval [CI] 1.387–7.230), followed by the high PAPi/low PAC (HR 2.388, 95%CI 1.075–5.305) and the low PAPi/high PAC groups (HR 2.266, 95%CI 0.962–5.334). Model discrimination—assessed using C-indices—was improved by the addition of both PAPi and PAC to the GWTG-HF score (C-index 0.688 vs. 0.652; ΔC-index +0.047, 95%CI 0.002– 0.100, P=0.038). Conversely, models incorporating PAPi or PAC alone did not significantly enhance discrimination. Conclusions In patients with decompensated advanced HF, early invasive hemodynamic phenotyping using combined PAPi-PAC enhances risk stratification beyond established clinical scores and may aid timely consideration of advanced therapies in high-risk individuals. Clinical Perspective What is New? Models incorporating both the pulmonary artery pulsatility index (PAPi) and pulmonary arterial capacitance (PAC) to the Get With The Guidelines-Heart Failure score demonstrated enhanced discriminatory ability. Incorporation of only PAPi or PAC alone did not significantly improve model discrimination. What Are the Clinical Implications? In patients with decompensated advanced HF, early invasive hemodynamic phenotyping using a combined PAPi-PAC approach enhances risk stratification. Combined PAPi-PAC assessment may aid decision-making regarding advanced therapies in high-risk individuals.