The prevalence of pulmonary hypertension associated with left heart disease: a systematic review and meta-analysis

Aims: Pulmonary hypertension (PH) is prognostic and a potentially modifiable cause of adverse outcome across the left heart disease (LHD) spectrum. However, data on the prevalence of PH-LHD analysed systematically using a contemporary diagnostic framework are lacking. Methods and results: We performed a systematic literature search including patients with heart failure with preserved or reduced ejection fraction (HFpEF, HFrEF), mitral regurgitation (MR), or aortic stenosis (AS) in three Western European countries (Austria, Germany, Switzerland; total population ∼102 million in 2024). Studies reporting peak tricuspid regurgitation velocity (TRV) from echocardiography or mean pulmonary arterial pressure (mPAP) from right heart catheterization were included. We used a two-strata system to classify PH-LHD: 'at-risk' (TRV >2.8 m/s) or 'manifest' (TRV >3.4 m/s in combination with mPAP >20 mmHg, to account for RHC referral bias). Meta-analysis was performed using a generalized linear mixed model. From n = 123 reports including 51 333 patients, there were n = 34, n = 17, n = 39, and n = 37 studies focusing on HFpEF, HFrEF, AS, and MR, respectively. PH prevalence estimates based on TRV > 2.8 m/s for patients with established HFpEF, HFrEF, AS, and MR were 62% [95% confidence interval (CI): 49-74%], 66% (95% CI: 57-74%), 73% (95% CI: 68-78%), and 80% (95% CI: 76-83%), respectively, and 20% (95% CI: 7-33%), 34% (95% CI: 24-43%), 38% (95% CI: 31-45%), and 54% (95% CI: 49-59%) when using TRV >3.4 m/s in combination with mPAP >20 mmHg, respectively. Extrapolation resulted in 2287 (95% CI: 1770-2804)/100 000 individuals 'at risk' and 805 (95% CI: 325-1285)/100 000 individuals with 'manifest' PH associated with heart failure (HFpEF and HFrEF combined). In addition, 712 (95% CI: 637-787)/100 000 individuals and 413 (95% CI: 347-480)/100 000 individuals had 'at risk' and 'manifest' PH associated with AS or MR, respectively. These collective data suggest that ∼2.7% of the population have 'at risk' and ∼1.0% 'manifest' PH-LHD in Austria, Germany, and Switzerland in 2024. Conclusion: The prevalence of PH in patients with from LHD is considerable, although estimates vary by cardiac subtype and specificity of diagnostic criteria. These data warrant prospective studies emphasizing focus on PH detection and management for people with LHD, particularly heart failure.