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

https://doi.org/10.1016/j.echo.2014.09.004Get 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.

References (25)

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