Accuracy of Echocardiography to Estimate Pulmonary Artery Pressures With Exercise

Abstract

Background Exercise echocardiography is often applied as a noninvasive strategy to screen for abnormal pulmonary hemodynamic response, but it is technically challenging and limited data exist regarding its accuracy to estimate pulmonary arterial pressure (PAP) during exercise. Methods and Results Among 65 patients with exertional intolerance undergoing upright invasive exercise testing, tricuspid regurgitation (TR) Doppler estimates and invasive measurement of PAP at rest and peak exercise were simultaneously obtained. TR Doppler envelopes were assessed for quality. Correlation, Bland-Altman, and receiver-operating characteristic curve analyses were performed to evaluate agreement and diagnostic accuracy. Mean age was 62±13 years and 31% were male. High quality (grade A) TR Doppler was present in 68% at rest and 34% at peak exercise. For grade A TR signals, echocardiographic measures of systolic PAP correlated reasonably well with invasive measurement at rest (r=0.72, p<0.001; bias=−2.9±8.0 mmHg) and peak exercise (r=0.75, p<0.001; bias=−1.9±15.6). Lower quality TR signals (grade B and C) correlated poorly with invasive measurements overall. In patients with grade A TR signals, mean PAP-to-workload ratio at a threshold of 1.4mmHg/10W, was able to identify abnormal pulmonary hemodynamic response during exercise (>3.0 mmHg/L/min increase), with 91% sensitivity and 82% specificity (AUC 0.90 [95% CI 0.77–1.0], p=0.001). Conclusions Agreement between echocardiographic and invasive measures of pulmonary pressures during upright exercise is good among the subset of patients with high quality TR Doppler signal. While the limits of agreement are broad, our results suggest that in those patients sensitivity is adequate to screen for abnormal pulmonary hemodynamic response during exercise.

Assessment of pulmonary vascular response to exercise with Doppler-echocardiography: state of the art?

“…The strength of this study is, that the investigators performed echocardiography and right heart catheterization simultaneously. The study showed high correlations of invasive and noninvasive assessments, both at rest and during exercise, as long as TRV signals revealed a good quality (9). At rest in 68% of patients TRV Doppler envelopes revealed a high quality and highly correlated with the invasive measurements.…”

“…In conclusion, the paper of van Riel et al (9) represents an important step forward in the awareness of possibilities and limitations of transthoracic Doppler-echocardiography for the evaluation of the pulmonary circulation. However, more research and evidences are urgently needed to test the reliability of TRV assessment in different clinical settings and to settle its standardization.…”

“…Routinely, its evaluation is performed by assessment of the tricuspid regurgitation velocity (TRV), which allows an estimation of systolic pulmonary arterial pressure (sPAP) (8). The recent work by van Riel and collaborators addresses the question, whether estimation of pulmonary pressures during exercise using stress-Doppler echocardiography is accurate and allows diagnostic statements (9). The strength of this study is, that the investigators performed echocardiography and right heart catheterization simultaneously.…”

“…The work of van Riel et al (9) sheds both lights and shadows at the assessment of the pulmonary vascular response to exercise. According to this work, the presence of a high quality TRV signal, characterised by both extension of the tricuspid signal lasting at least half of systole, as well as the presence of well-defined TRV borders, confers a reliable predictive power of resting and exercise pulmonary pressures.…”

Exercise Doppler echocardiography for the diagnosis of pulmonary hypertension: renewed interest and evolving roles

“…In the study by van Riel et al, the authors compared the use of Doppler echocardiography to right-heart catheterisation at detecting PHT in a cohort of patients presenting with exertional intolerance but no prior history of PHT (11). The tricuspid regurgitation (TR) signals on Doppler echocardiogram were used for pulmonary artery pressure (PAP) calculations, which include systolic pulmonary artery pressure (SPAP) estimation from peak TR velocity and MPAP estimation from the TR velocity-time integral envelop.…”