Variability in Hemodynamic Evaluation of Pulmonary Hypertension at Large Referral Centers

Abstract

Despite consensus guidelines for right heart catheterization (RHC) in the diagnosis of pulmonary arterial hypertension (PAH), considerable differences exist in the performance of RHC, interpretation of hemodynamic data, and frequency of RHC performance in patients with established disease. These differences may lead to variability in diagnosis or treatment of PAH. We sought to gather information on the standard practice of RHC for the diagnosis and management of PAH from experienced pulmonary vascular disease specialists. We developed a semiquantitative online survey of diagnosis and treatment patterns of pulmonary hypertension and distributed it to physicians at pulmonary hypertension centers in the United States. Thirty of 50 physicians completed the survey: 20 pulmonologists and 10 cardiologists, all of whom reported treating >100 patients with PAH in the past year. All respondents perform RHC in ≥90% of patients with suspected PAH. All physicians determine the pulmonary wedge pressure at end expiration; however, only half of respondents personally review tracings. Physicians differed in frequency of vasodilator testing (8 of 24 performed testing in >90% of patients with PAH), fluid challenge and exercise (19 of 30 performed testing in <25% of patients with PAH for both). Most physicians (70%) report repeating RHC between 6 months and 1 year after PAH treatment initiation. Variability exists in the interpretation of hemodynamic tracings and performance of vasodilator, fluid, and exercise challenges in the management of PAH by experienced physicians in the United States. Additional consensus guidelines delineating appropriate adjunctive testing to standardize the diagnosis of PAH are needed.

Mortality in US veterans with pulmonary hypertension: a retrospective analysis of survival by subtype and baseline factors

“…Multiple prior investigators-using varied methods including cell and animal models, translational research, and epidemiologic studies-have shown that metabolic conditions such as glucose intolerance, diabetes mellitus, and the metabolic syndrome are closely linked to pulmonary vascular conditions such as PAH and hypoxiamediated PH. [33][34][35][36][37][38][39][40] One prior report on the impact of diabetes mellitus on PAH survival showed increased risk for death, consistent with our findings. 40 Whether intervention on these metabolic processes would mitigate the increase in risk of disease is unknown; although a prior study had been posed (NCT00825266 at clinicaltrials.gov 41 ), no study has been completed.…”

Survey of practices in relation to chronic pulmonary hypertension in neonates in the Canadian Neonatal Network and the National Institute of Child Health and Human Development Neonatal Research Network

“…There are some important limitations to our study. First , we did not have responses from all CNN and NRN sites, and while this is a common complication of this study design, our overall response rate was comparable with similar studies 24 , 25 . Further, the majority of units that responded had high patient volumes, likely accounting for a large proportion of cPH‐related practices within the network.…”

“…First , we did not have responses from all CNN and NRN sites, and while this is a common complication of this study design, our overall response rate was comparable with similar studies. 24 , 25 Further, the majority of units that responded had high patient volumes, likely accounting for a large proportion of cPH-related practices within the network. Second , while CNN includes all tertiary centers in Canada, NRN is one of the several major neonatal networks existing in the United States and may not reflect management practices on a national scale.…”

“…While the use of echocardiography as a screening tool was almost universal between sites in both networks, NRN sites were more likely to have a standardized management approach, employ cardiac catheterization in the diagnostic work-up, and prescribe conservative treatment measures in First line 6 (75) 2 (25) 0 (0) 0 (0) Second line 0 (0) 6 (75) 0 (0) 2 (25) Values are listed as frequency (percentage). Centers were asked to only rank therapies currently in use in their respective site.…”

Will the Real Pulmonary Pressure Please Stand Up?

“…Direct measurement of left ventricular end-diastolic pressure may also be warranted ( 5 ). Precision in hemodynamic evaluation and reporting is crucial because the RHC operator is commonly not the treating provider, and even at experienced PH centers, only 50% of the clinicians will subsequently review the hemodynamic tracings themselves ( 6 ). Melillo and colleagues are to be congratulated given the clinical relevance of their findings.…”