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Evaluation of the Impact of an Echocardiographic Diagnosis of Pulmonary Hypertension on Patient Outcomes

ABSTRACT: Background Although detection of elevated right ventricular systolic pressure (RVSP) on routine echocardiography is common, its clinical significance is underappreciated. The recent change in the hemodynamic definition of pulmonary hypertension (PH) lowering the threshold from mean pulmonary arterial pressure ? 25 mm Hg to > 20 mm Hg further clouds the picture. Methods A retrospective cohort study was performed on residents of the South East Local Health Integration Network (population 495,000), Ontario, Canada, who underwent transthoracic echocardiography at the Kingston Health Sciences Centre between February 19, 2013, and December 31, 2016. The index echocardiography from 9291 unique patients was obtained. Results A total of 2049 patients (22.1%) had an RVSP ? 40 mm Hg, 2040 patients (22.0%) had an RVSP ? 30 and < 40 mm Hg, but only 284 patients (3.1%) had a clinical diagnosis of PH. Although patients with an RVSP ? 40 mm Hg had the highest Charlson Comorbidity Index (CCI) (1.81 ± 0.05) and number of hospitalizations 1 year before the echocardiography (1.24 ± 0.03), patients with RVSP between 30 and 40 mm Hg also had significantly higher CCI (1.19 ± 0.04) and hospitalization (0.87 ± 0.03) compared with the CCI (0.84 ± 0.03) and hospitalization (0.65 ± 0.02) of patients with RVSP < 30 mm Hg (P < 0.0001). Conclusion Despite the finding that an elevated RVSP ? 30 mm Hg is common and predicts adverse outcomes, most patients with elevated RVSP are not reported as having PH or investigated. The significance of the elevated RVSP is underappreciated.

SUBMITTER: Xiong P

PROVIDER: S-EPMC7499396 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Project description:We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100-2.197) vs. 0.208 (0.026-0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731-0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25-1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH.

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Evaluation of the Impact of an Echocardiographic Diagnosis of Pulmonary Hypertension on Patient Outcomes

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