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Comment & Response
March 25, 2020

Echocardiographic Pulmonary Hypertension and Right Heart Function—The Big Picture—Reply

Author Affiliations
  • 1Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2Vanderbilt Translational and Cardiovascular Clinical Research Center, Vanderbilt University Medical Center, Nashville, Tennessee
JAMA Cardiol. 2020;5(5):613. doi:10.1001/jamacardio.2020.0325

In Reply We appreciate the kind words by Mehmood and echo many of his concerns about how to integrate this knowledge into clinical practice. In our recent publication,1 we demonstrated that there was increased mortality risk with mild echocardiographic pulmonary hypertension (PH) and that these mild elevations in were associated with reduced right ventricular (RV) function and RV–pulmonary artery (PA) coupling. The US expert consensus recommends a threshold RV systolic pressure (RVSP) of 40 mm Hg for further investigation of pulmonary pressures, which our data suggest inadequately captures risk in a patient population being assessed for cardiopulmonary symptoms.2 This idea is further supported by recent reconsideration of the hemodynamic definition of PH at the sixth World Symposium on Pulmonary Hypertension. The diagnostic threshold for PH was lowered to a mean PA pressure of 20 mm Hg, which corresponds approximately to a systolic pressure of 33 mm Hg. We thought it was important to examine risk using echocardiographic data because most patients with PH, particularly with heart failure or chronic obstructive pulmonary disease, never undergo invasive hemodynamic assessment. Although our data derived from an electronic health record cohort, data from the Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction (PARAGON-HF) randomized clinical trial,3 which were collected according to a standardized protocol and interpreted in a central core laboratory, also found an increased risk of clinical events beginning at an estimated RVSP of approximately 33 mm Hg.

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