Prevalence and Factors Associated With Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction: A Meta-Analysis and Meta-Regression

Pulmonary hypertension (PH) is one of the unfavorable clinical turning points in the natural history of heart failure with preserved ejection fraction (HFpEF). However, as it is identified as an independent predictor of worse prognosis, its true prevalence is uncertain. This review aims to investigate the pooled prevalence, associated risk factors, and characteristics of patients with PH-HFpEF. Systematic searches of 3 databases (PubMed, ScienceDirect, and Scopus) with citation searching were conducted. Studies conducting direct surveillance using echocardiography or catheterization for estimating the prevalence of PH-HFpEF patients (left ventricular ejection fraction ≥50%) were included. The Newcastle-Ottawa scale was used for quality assessment. RStudio was used for statistical analysis. This review comprises 11 studies (n = 1838 patients) that met the eligibility criteria. The pooled prevalence of PH-HFpEF was 0.63 (95% CI, 0.52-0.74). This value was robust based on leave-one-out and cumulative sample sensitivity analysis. Meta-regression revealed a significant relationship between PH prevalence and several associated factors, including history of coronary artery disease (β = 0.50; P < 0.0001), baseline female sex (β = 0.49; P < 0.0001), hypertension (β = 0.49; P < 0.0001), and diabetes (β = 0.46; P < 0.0001). Meta-analyses of echocardiography characteristics revealed that patients with PH-HFpEF have significantly worse diastolic function and more advanced left atrial remodeling compared to those without PH. In conclusion, PH was present in over half of HFpEF patients at baseline, with a history of coronary artery disease, female sex, hypertension, and diabetes significantly associated with greater susceptibility, emphasizing risk-based screening across these HFpEF phenotypes.