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A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension.

ABSTRACT: Pulmonary hypertension (PH) has diverse causes with heterogeneous physiology compelling distinct management. Differentiating patients with primarily elevated pulmonary vascular resistance (PVR) from those with PH predominantly because of elevated left-sided filling pressure is critical.We reviewed hemodynamics, echocardiography, and clinical data for 108 patients seen at a referral PH clinic with transthoracic echocardiogram and right heart catheterization within 1 year. We derived a simple echocardiographic prediction rule to allow hemodynamic differentiation of PH attributed to pulmonary vascular disease (PH(PVD), defined as pulmonary artery wedge pressure [PAWP]?15 mm Hg and PVR>3 WU). Age averaged 61.3±14.8 years, ?PAWP and PVR were 16.4±7.1 mm Hg and 6.3±4.0 WU, respectively, and 52 (48.1%) patients fulfilled PH(PVD) hemodynamic criteria. The derived prediction rule ranged from -2 to +2 with higher scores suggesting higher probability of PH(PVD): +1 point for left atrial anterior-posterior dimension <3.2 cm; +1 for presence of a mid systolic notch or acceleration time <80 ms; -1 for lateral mitral E:e'>10; -1 for left atrial anterior-posterior dimension >4.2 cm. PVR increased stepwise with score (for -2, 0, and +2, ?PVR were 2.5, 4.5, and 8.1 WU, respectively), whereas the inverse was true for pulmonary artery wedge pressure (corresponding ?PAWP were 21.5, 16.5, and 10.4 mm Hg). Among subjects with complete data, the score had an area under the curve (AUC) of 0.921 for PH(PVD). A score ?0 had 100% sensitivity and 69.3% positive predictive value for PH(PVD), with 62.3% specificity. No patients with a negative score had PH(PVD). Patients with a negative score and acceleration time >100 ms had normal PVR (?PVR=1.8 WU, range=0.7-3.2 WU).We present a simple echocardiographic prediction rule that accurately defines PH hemodynamics, facilitates improved screening and focused clinical investigation for PH diagnosis and management.

SUBMITTER: Opotowsky AR

PROVIDER: S-EPMC3505751 | biostudies-literature | 2012 Nov

REPOSITORIES: biostudies-literature

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A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension.

Opotowsky Alexander R AR Ojeda Jason J Rogers Frances F Prasanna Vikram V Clair Mathieu M Moko Lilamarie L Vaidya Anjali A Afilalo Jonathan J Forfia Paul R PR

Circulation. Cardiovascular imaging 20120822 6

<h4>Background</h4>Pulmonary hypertension (PH) has diverse causes with heterogeneous physiology compelling distinct management. Differentiating patients with primarily elevated pulmonary vascular resistance (PVR) from those with PH predominantly because of elevated left-sided filling pressure is critical.<h4>Methods and results</h4>We reviewed hemodynamics, echocardiography, and clinical data for 108 patients seen at a referral PH clinic with transthoracic echocardiogram and right heart catheter ...[more]

PMID: 22914595

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Project description:Echocardiography is the gold standard non-invasive technique to diagnose pulmonary hypertension. It is also an important modality used to monitor disease progression and response to treatment in patients with pulmonary hypertension. Surprisingly, only few studies have been conducted to validate and standardize echocardiographic parameters in experimental animal models of pulmonary hypertension. We sought to define cut-off values for both invasive and non-invasive measures of pulmonary hemodynamics and right ventricular hypertrophy that would reliably diagnose pulmonary hypertension in three different rat models. The study was designed in two phases: (1) a derivation phase to establish the cut-off values for invasive measures of right ventricular systolic pressure, Fulton's index (right ventricular weight/left ventricle?+?septum weight), right ventricular to body weight ratio, and non-invasive echocardiographic measures of pulmonary arterial acceleration time, pulmonary arterial acceleration time to ejection time ratio and right ventricular wall thickness in diastole in the hypoxic and monocrotaline rat models of pulmonary hypertension and (2) a validation phase to test the performance of the cut-off values in predicting pulmonary hypertension in an independent cohort of rats with Sugen/hypoxia-induced pulmonary hypertension. Our study demonstrates that right ventricular systolic pressure ?35.5?mmHg and Fulton's Index ?0.34 are highly sensitive (>94%) and specific (>91%) cut-offs to distinguish animals with pulmonary hypertension from controls. When pulmonary arterial acceleration time/ejection time and right ventricular wall thickness in diastole were both measured, a result of either pulmonary arterial acceleration time/ejection time ?0.25 or right ventricular wall thickness in diastole ?1.03?mm detected right ventricular systolic pressure ?35.5?mmHg or Fulton's Index ?0.34 with a sensitivity of 88% and specificity of 100%. With properly validated non-invasive echocardiography measures of right ventricular performance in rats that accurately predict invasive measures of pulmonary hemodynamics, future studies can now utilize these markers to test the efficacy of different treatments with preclinical therapeutic modeling.

Project description:Importance:Current guidelines recommend evaluation for echocardiographically estimated right ventricular systolic pressure (RVSP) greater than 40 mm Hg; however, this threshold does not capture all patients at risk. Objectives:To determine if mild echocardiographic pulmonary hypertension (ePH) is associated with reduced right ventricular (RV) function and increased risk of mortality. Design, Setting, and Participants:In this cohort study, electronic health record data of patients who were referred for echocardiography at Vanderbilt University Medical Center, Nashville, Tennessee, from March 1997 to February 2014 and had recorded estimates of RVSP values were studied. Data were analyzed from February 2017 to May 2019. Exposures:Mild ePH was defined as an RVSP value of 33 to 39 mm Hg. Right ventricular function was assessed using tricuspid annular plane systolic excursion (TAPSE), and RV-pulmonary arterial coupling was measured using the ratio of TAPSE to RVSP. Main Outcomes and Measures:Associations of mild ePH with mortality adjusted for relevant covariates were examined using Cox proportional hazard models with restricted cubic splines. Results:Of the 47?784 included patients, 26?758 of 47?771 (56.0%) were female and 6040 of 44?763 (13.5%) were black, and the mean (SD) age was 59 (18) years. Patients with mild ePH had worse RV function compared with those with no ePH (mean [SD] TAPSE, 2.0 [0.6] cm vs 2.2 [0.5] cm; P?<?.001) and nearly double the prevalence of RV dysfunction (32.6% [92 of 282] vs 16.7% [170 of 1015]; P?<?.001). Compared with patients with RVSP less than 33 mm Hg, those with mild ePH also had reduced RV-pulmonary arterial coupling (mean [SD] ratio of TAPSE to RVSP, 0.55 [0.18] mm/mm Hg vs 0.93 [0.39] mm/mm Hg; P?<?.001). An increase in adjusted mortality began at an RVSP value of 27 mm Hg (hazard ratio, 1.32; 95% CI, 1.02-1.70). Female sex was associated with increased mortality risk at any given RVSP value. Conclusions and Relevance:Mild ePH was associated with RV dysfunction and worse RV-pulmonary arterial coupling in a clinical population seeking care. Future studies are needed to identify patients with mild ePH who are susceptible to adverse outcomes.

Project description:ObjectiveWe aimed to identify the echocardiographic measures associated with survival in a patient population with a high prevalence of co-morbid cardiovascular and pulmonary disease that have significantly elevated estimated pulmonary artery systolic pressures (ePASP).BackgroundPulmonary hypertension (PH) is a clinical feature of several cardiopulmonary diseases that are prevalent among elderly. While certain echocardiographic parameters have been shown to be important in the prognosis in specific PH groups, the prognostic relevance of echocardiographic characteristics in a cohort with multiple cardiopulmonary comorbidities is unclear.MethodsWe retrospectively identified 152 patients with ePASP > 60 mmHg by echocardiography over a five year period (6/2006-11/2011) and followed until 4/2013. Candidate clinical and echocardiographic characteristics suggestive of PH severity were compared between deceased and surviving subpopulations. Cox proportional hazard modeling was used to identify echocardiographic predictors of death adjusted for age and clinical characteristics.ResultsThis was a predominantly elderly (age 78.8 ± 10.2 years), male (98.7%) cohort with several cardiopulmonary comorbidities. Overall mortality was high (69.7%, median survival 129 days). After adjusting for age and clinical characteristics, decreased right ventricular (RV) systolic function assessed by tricuspid annular plane systolic excursion (HR 0.56, 95% CI 0.33-0.96, p = 0.034) and increased RV thickness (HR: 4.34, 95% CI: 1.49-12.59, p = 0.007) were independently associated with mortality. In contrast, left ventricular systolic function, left ventricular diastolic parameters, ePASP, or echo-derived pulmonary vascular resistance (PVR) were not associated with increased mortality.ConclusionIn a cohort of patients with PH and high prevalence of cardio-pulmonary comorbidities, RV systolic function and hypertrophy are associated with mortality and may be the most relevant echocardiographic markers for prognosis.

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A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension.

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A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension.

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