Supplementary Material for: Combined Effects of Pulmonary Hypertension and Heart Valve Calcification on Cardiovascular Outcomes in Maintenance Hemodialysis Patients: A Risk Stratification Study Using Echocardiography

Background: Cardiovascular disease remains the leading cause of mortality in maintenance hemodialysis (MHD) patients. While both pulmonary hypertension (PH) and heart valve calcification (HVC) are established independent risk factors for adverse outcomes in this population, the synergistic effect of these two echocardiographic parameters on cardiovascular prognosis has not been well investigated.
Methods: In this prospective study, we analyzed clinical and echocardiographic data from 302 MHD patients over a two-year follow-up period. Patients were stratified into three groups based on the presence of risk factors: group 1 (no risk factors), group 2 (either PH or HVC), and group 3 (both PH and HVC). Survival analysis was performed using Kaplan-Meier curves, and Cox regression models were employed to evaluate the impact on all-cause mortality, cardiovascular mortality, and new-onset cardiovascular events (CV events).
Results: During follow-up, 63 patients (20.9%) died from all causes, with 36 deaths (57.1%) attributed to CV events. Cardiovascular mortality was significantly higher in Groups 2 (13.2%) and 3 (30.2%) compared to Group 1 (5.1%; p<0.001). New-onset CV events occurred in 33.1% of patients, with rates of 20.3%, 35.5%, and 67.4% in Groups 1, 2 and 3, respectively (p<0.001). The presence of both PH and HVC was associated with a higher risk of all-cause mortality, cardiovascular mortality, and new-onset CV events compared to either PH or HVC alone. After adjusting for confounders, the combination of PH and HVC remained a significant predictor, demonstrating a higher risk than having a single risk factor [HR for all-cause mortality: 3.76 (95% CI: 1.83-7.73) vs. 1.90 (95% CI: 1.03-3.52); HR for cardiovascular mortality: 9.23 (95% CI: 3.42-24.95) vs. 3.11 (95% CI: 1.23-7.84); HR for new-onset CV events: 4.21 (95% CI: 2.39-7.21) vs. 1.68 (95% CI:1.01-2.76)].
Conclusions: The coexistence of PH and HVC significantly increases cardiovascular risk compared to either condition alone in MHD patients. Echocardiography is a valuable tool for screening and risk stratification in this high-risk population by identifying both PH and HVC.