Two Simple Echo-Doppler Measurements Can Accurately Identify Pulmonary Hypertension in the Large Majority of Patients With Chronic Heart Failure

doi:10.1016/j.healun.2004.03.026

The Journal of Heart and Lung Transplantation

Volume 24, Issue 6, June 2005, Pages 745-754

https://doi.org/10.1016/j.healun.2004.03.026 Get rights and content

Background

The assessment of pulmonary hypertension in patients with heart failure is of great clinical importance not only for diagnostic purposes but also for prognostication. The present study was undertaken on a consecutive basis with a group of patients with chronic heart failure. Patients were evaluated for their suitability for heart transplantation: (1) to explore the diagnostic accuracy of several echo Doppler parameters of pulmonary hemodynamics in predicting the presence of elevated pulmonary artery pressure (defined as pulmonary artery systolic pressure ≥35 mm Hg and mean pulmonary artery pressure >20 mm Hg); (2) to assess the diagnostic ability of the same parameters to identify patients with elevated pulmonary vascular resistance; and (3) to evaluate the influence of right ventricular function and degree of tricuspid regurgitation in modifying diagnostic accuracy.

Methods

Echo Doppler examination and right heart catheterization were performed consecutively within 24 hours in 86 patients. The optimal cut-off value for a series of echo Doppler parameters capable of identifying patients with pulmonary hypertension was obtained by dividing the entire sample into 2 groups; the optimal threshold (highest sensitivity and specificity) of the echo and Doppler parameters used to classify patients with and without pulmonary hypertension was determined in 67% of cases by means of the receiver operating characteristic (ROC) curve: this was the testing sample. The proportion of cases classified correctly according to the selected cut-off was computed. The remaining 33% of cases represented the validation sample: sensitivity, specificity and predictive values (and their 95% confidence intervals [CIs]) for identifying pulmonary hypertension were calculated from the proposed cut-offs in this second sample. Finally, the overall performance of the echo Doppler parameters was assessed over the whole sample by considering the extent of the area under the ROC curve (A-ROC) and its 95% CI, for the dichotomic measurement.

Results

On right heart catheterization, a pulmonary artery systolic (PAPs) pressure ≥35 mm Hg plus a mean pressure (mean PAP) >20 mm Hg was documented in 49 of 86 cases (57%), for whom mean values were 56 ± 17 and 38 ± 11 mm Hg, respectively. The proportion of cases identified correctly as having pulmonary hypertension was highest for PAPs (88%) and mean PAP (85%) in addition to acceleration time of pulmonary artery systolic flow (ACT) (79%) and pulmonary artery diastolic pressure obtained utilizing the early phase of the tricuspid regurgitation spectral flow (PAPd/TR) (75%). PAPd/TR performed better in the validating sample in terms of diagnostic ability, with high sensitivity and specificity (100% and 60%) and positive and negative predictive values (PPV 80%, NPV 100%). PAPs, mean PAP, ACT and PAPd/TR confirmed their prevailing diagnostic ability (A-ROC from 0.74 to 0.86) in identifying pulmonary hypertension with fair to high feasibility (67% to 91%) and an odds ratio (OR) indicative of strong association. ACT and PAPd/TR, the 2 parameters with the highest feasibility, allowed us to identify 46 of 49 (94%) hypertensive cases. The same parameters did not perform well in identifying patients with increased vascular resistance, with A-ROC ranging from 0.55 to 0.69. Heterogeneity of effect, due to right ventricular function or tricuspid regurgitation degree, could not be demonstrated in the ability of the echo Doppler measurements to identify pulmonary hypertension.

Conclusions

ACT, PAPd/TR, PAPs and mean PAP have been shown to accurately classify patients with chronic heart failure with or without pulmonary hypertension. In particular, ACT and PAPd/TR alone allowed reliable and accurate definition of pulmonary hypertension in 94% of patients, regardless of right ventricular function or degree of tricuspid regurgitation. Non-invasive pulmonary pressure assessment by the referred method might be useful in the evaluation of heart transplant candidates.

Section snippets

Study Population

Eighty-six patients were included in the study on a consecutive basis. All patients had a history of heart failure and were referred to our center for evaluation as candidates for heart and/or lung transplantation.

The study population is presented in Table 2. All patients who were referred to our clinic from other centers during the study period were included in the analysis, thus explaining the presence of some cases with primary pulmonary involvement or fairly good cardiac condition at the

Right Heart Catheterization Results

Right heart catheterization results are reported in Table 3.

At right heart catheterization, a PAPs ≥35 mm Hg plus mean PAP >20 mm Hg was documented in 49 of 86 patients (57%) in whom PAPs and mean PAP were 56 ± 17 and 38 ± 11 mm Hg, respectively, compared with values of 24 ± 7 and 17 ± 7 mm Hg in the remaining 37 patients (43%) (p < 0.001).

EchoDoppler Results

The echoDoppler results are given in Table 4. Our population showed a reduction in both left and right ventricular function, ranging from mild to moderate in

Discussion

In this study we tried to define the diagnostic accuracy of different echo and Doppler parameters of pulmonary hemodynamics and to determine which one best predicts the presence of elevated pulmonary pressures in a group of patients evaluated consecutively and submitted to right heart catheterization within a 24-hour period. The proportion of cases identified correctly as having pulmonary hypertension was highest for PAPs at 88%, compared with 85% for mean PAP, 79% for ACT and 75% for PAPd/TR.

Conclusions

ACT, PAPd/TR, PAPs and mean PAP have been shown to classify accurately patients with chronic heart failure with or without pulmonary hypertension. Our study has demonstrated that analysis of the first 2 echo Doppler parameters allows for a reliable and accurate definition of pulmonary hypertension in the large majority of patients. This result may transform a usually cumbersome and time-consuming non-invasive tool into an alternatively feasible one in the routine follow-up of patients with

References (30)

J.H. Stein et al.
Echo for hemodynamic assessment of patients with advanced heart failure and potential heart transplant recipients
J Am Coll Cardiol
(1997)
F. Scapellato et al.
Accurate noninvasive estimation of pulmonary vascular resistance by Doppler echocardiography in patients with chronic heart failure
J Am Coll Cardiol
(2001)
S. Capomolla et al.
Invasive and non-invasive determinants of pulmonary hypertension in patients with chronic heart failure
J Heart Lung Transplant
(2000)
S. Ghio et al.
Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure
J Am Coll Cardiol
(2001)
P. De Groote et al.
Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure
J Am Coll Cardiol
(1998)
D. Turkevich et al.
Early partial closure of the pulmonic valve relates to severity of pulmonary hypertension
Am Heart J
(1988)
M. Berger et al.
Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound
J Am Coll Cardiol
(1985)
P.J. Currie et al.
Continuous wave Doppler determination of right ventricular pressurea simultaneous Doppler-catheterization study in 127 patients
J Am Coll Cardiol
(1985)
R.T. Lee et al.
Prospective Doppler echocardiographic evaluation of pulmonary artery diastolic pressure in the medical intensive care unit
Am J Cardiol
(1989)
B.J. Kircher et al.
Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava
Am J Cardiol
(1990)

A. Dabestani et al.

Evaluation of pulmonary artery pressure and resistance by pulsed Doppler echocardiography

Am J Cardiol

(1987)

R. Martin-Duran et al.

Comparison of Doppler-determined elevated pulmonary arterial pressure with pressure measured at cardiac catheterisation

Am J Cardiol

(1986)

S.V. Abramson et al.

Use of multiple views in the echocardiographic assessment of pulmonary artery systolic pressure

J Am Soc Echocardiogr

(1995)

B. Stephen et al.

Non invasive estimation of pulmonary artery diastolic pressure in patients with tricuspid regurgitation by Doppler echocardiography

Chest

(1999)

L. Lanzarini et al.

Noninvasive estimation of both systolic and diastolic pulmonary artery pressure from Doppler analysis of tricuspid regurgitant velocity spectrum in patients with chronic heart failure

Am Heart J

(2002)

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Failing heart—medical aspectTwo Simple Echo-Doppler Measurements Can Accurately Identify Pulmonary Hypertension in the Large Majority of Patients With Chronic Heart Failure

Background

Methods

Results

Conclusions

Section snippets

Study Population

Right Heart Catheterization Results

EchoDoppler Results

Discussion

Conclusions

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Failing heart—medical aspect
Two Simple Echo-Doppler Measurements Can Accurately Identify Pulmonary Hypertension in the Large Majority of Patients With Chronic Heart Failure