Echocardiographic Prediction of Pre- versus Postcapillary Pulmonary Hypertension

doi:10.1016/j.echo.2014.09.004

Journal of the American Society of Echocardiography

Volume 28, Issue 1, January 2015, Pages 108-115

https://doi.org/10.1016/j.echo.2014.09.004 Get rights and content

Background

The differential diagnosis between pre- and postcapillary pulmonary hypertension (PH) is of major therapeutic relevance and thus requires optimal clinical probability assessment with echocardiography.

Methods

We prospectively analyzed 152 consecutive patients referred to a PH center over a 1-year period undergoing quasi-simultaneous (within 1 hour) echocardiography and right heart catheterization. Echocardiography was performed as usually recommended for the assessment of PH and left heart conditions. PH was defined as a mean pulmonary artery pressure ≥ 25 mm Hg. Postcapillary PH was diagnosed on the basis of a pulmonary capillary wedge pressure >15 mm Hg.

Results

Ten of 152 patients (7%) had no PH, 81 of 152 (53%) had precapillary PH, and 61 of 152 (40%) had postcapillary PH. The following five echocardiographic variables were found to predict precapillary PH: right heart chamber larger than the left (P = .0018), left ventricular eccentricity index > 1.2 (P = .0039), dilated inferior vena cava without inspiratory collapse (P = .0076), E/e′ ratio ≤10 (P = .00001), and the right ventricle forming the heart apex (P = .0144). Beta coefficients from multiple logistic regression were significant for dilated inferior vena cava without inspiratory collapse (P = .0464) and E/e′ ratio ≤ 10 (P = .0002). The score based on β coefficients, ranging from 3 to 34 points, resulted in optimal discrimination at >5, with a positive predictive value of 67.9% and a negative predictive value of 77.5% for precapillary PH.

Conclusion

Echocardiography enables a clinically satisfactory differential diagnosis between pre- and postcapillary PH.

Section snippets

Methods

In June 2011, we started a prospective study that lasted until May 2012, with two main purposes: (1) to compare invasive versus noninvasive measurements of the pulmonary circulation using rigorous Bland-Altman analysis, whose results have recently been published,¹⁰ and (2) to predict pre- versus postcapillary PH from echocardiographic measurements, which was the objective of the present study. One hundred twenty-two of 152 patients (80%) were included in two studies, and the same number of

Results

Nine of 161 patients (5.6%) were excluded from the study because of inadequate echocardiographic image quality. No patient showed echocardiographic signs of PH in the presence of estimated systolic PAP < 37 mm Hg. Demographics of the remaining 152 patients are summarized in Table 1; 81 of 152 patients (53%) had precapillary PH and 61 of 152 (40%) had postcapillary PH. Ten patients (7%) did not meet the diagnostic criteria for PH (mean PAP < 25 mm Hg on RHC).

Discussion

Our findings show that a simple echocardiographic score integrating measurements of right and left heart chamber dimensions with estimates of RV and LV filling pressures may discriminate between pre- and postcapillary PH with reasonable accuracy.

We aimed to develop a simple echocardiographic score on the basis of recommended measurements,3, 4 being realistic with respect to the daily clinical practice of most echocardiography laboratories. As a consequence, time-consuming performance indices,

Conclusions

Echocardiography should be part of the clinical evaluation reflecting the pathophysiology and left and right heart remodeling in different PH scenarios. We underscore the importance of some easy-to-measure and reproducible echocardiographic parameters, providing a simple rule able to predict the presence of pre- or postcapillary PH. Further investigations are needed to verify the reliability and the clinical effectiveness of this score in a larger patient population compared with “usual”

Acknowledgments

The authors are grateful to Mrs Antonella Nannolo for her contribution in this paper.

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Citation Excerpt :
The alternative is to improve the appropriateness of RHC by limiting it to patients with higher likelihood of precapillary PH. Multiparametric scores and noninvasive imaging indices have been previously proposed to define the probability of precapillary PH in patients with echocardiographically estimated high pulmonary pressures.6,8,10 D'Alto et al.6 proposed a multiparametric scoring system (eight parameters) to predict precapillary PH. The score was derived in a relatively small population and validated internally. The AUC was 0.75.
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BCI is a novel, noninvasive index based on routinely available echocardiographic parameters that identifies with high accuracy patients with precapillary PH. BCI may be of value in the screening workup of patients with PH.
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Pulmonary hypertension (PH) due to left heart disease (LHD) is a frequent complication of heart failure (HF) and is associated with exercise intolerance, poor quality of life, increased risk of hospitalisations, and reduced overall survival. Since the recent Sixth World Symposium on Pulmonary Hypertension in 2018, there have been significant changes in the hemodynamic definitions and clinical classification of PH-LHD. PH-LHD can be subdivided into (1) isolated postcapillary PH (IpcPH) and (2) combined precapillary and postcapillary PH (CpcPH). This categorisation of PH-LHD is important because CpcPH shares certain pathophysiologic, clinical, and hemodynamic characteristics with pulmonary arterial hypertension and is associated with worse outcomes compared with IpcPH. A systematic approach using clinical history and noninvasive investigations is required in the diagnosis of PH-LHD. Right heart catheterisation with and without provocative testing is performed in expert centres and is indicated in selected individuals. Although the definition of IpcPH and CpcPH is based on measurements made with right heart catheterisation, distinguishing between these two entities is not always necessary. Despite strong evidence for medical therapy in patients with pulmonary arterial hypertension, those options have limited benefit in PH-LHD. Expert PH centres in Canada have been established to provide ongoing care for the more complex patient subgroups.
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Clinical InvestigationPulmonary HypertensionEchocardiographic Prediction of Pre- versus Postcapillary Pulmonary Hypertension

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgments

Definitions and diagnosis of pulmonary hypertension

J Am Coll Cardiol

ACCF/AHA 2009 expert consensus document on pulmonary hypertension. A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association

Circulation

Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

J Am Soc Echocardioogr

Echocardiography in pulmonary arterial hypertension: from diagnosis to prognosis

J Am Soc Echocardiogr

Comparison of Doppler echocardiography and right-heart catheterization to assess pulmonary hypertension in systemic sclerosis

Br J Rheumatol

Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease

Am J Respir Crit Care Med

Estimating pulmonary artery pressures by echocardiography in patients with emphysema

Eur Respir J

Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension

Am J Respir Crit Care Med

Inaccuracy of Doppler echocardiographic estimates of pulmonary artery pressures in patients with pulmonary hypertension

Chest

Accuracy and precision of echocardiography versus right heart catheterization for the assessment of pulmonary hypertension

Int J Cardiol

Updated clinical classification of pulmonary hypertension

J Am Coll Cardiol

Updated treatment algorithm of pulmonary arterial hypertension

J Am Coll Cardiol

Clinical Investigation
Pulmonary Hypertension
Echocardiographic Prediction of Pre- versus Postcapillary Pulmonary Hypertension