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Comment & Response
March 25, 2020

Echocardiographic Pulmonary Hypertension and Right Heart Function—The Big Picture

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, The University of Tennessee Medical Center, Knoxville
JAMA Cardiol. Published online March 25, 2020. doi:10.1001/jamacardio.2020.0322

To the Editor Huston et al1 deserve a standing ovation for their seminal work published in a recent issue of JAMA Cardiology. The association of mild pulmonary hypertension (PH) with right ventricular (RV)–pulmonary artery (PA) coupling, estimated by echocardiography, and its prognostic significance in a large, racially mixed, unselected population lives up to the promise of capturing the big picture of PH and RV-PA interactions.1,2 Despite that noninvasive estimation of RV-PA coupling by the ratio of tricuspid annular plane systolic excursion to PA systolic pressure may not be the most ideal for serial assessment of the critically ill, in whom novel invasive techniques should be validated,3,4 the findings of Huston et al1 leave little doubt in the value of echocardiography as a screening tool.

An important question is how to best incorporate the accumulating data on the prognostic significance of PH and RV-PA coupling into investigation and clinical practice. While Huston et al1 appropriately although somewhat conservatively drew inferences from their data, the scientific community needs to embrace a multifaceted approach to translate these findings. First, guidelines on the use of echocardiography for monitoring therapeutic interventions should be promptly updated to reflect the accumulating body of evidence.5 Second, clinicians should be reminded to report tricuspid annular plane systolic excursion and PA systolic pressure as accurately as possible and indicate when the data are not reliable. Third, exploratory analyses of landmark trials in cardiopulmonary medicine, if feasible, should report the impact of therapeutic interventions on echocardiographic RV-PA coupling to add to the evidence. Lastly, future trials of therapeutic investigations, especially in comorbid cardiopulmonary diseases associated with more than mild PH, should entertain echocardiographic assessment of RV-PA coupling as a surrogate end point. Encouragingly, the big picture of RV-PA coupling appears to be getting in plain sight.

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Article Information

Corresponding Author: Muddassir Mehmood, MD, Division of Cardiology, Department of Medicine, The University of Tennessee Medical Center, 1940 Alcoa Hwy, Ste E180, Knoxville, TN 37920 (mmehmood@utmck.edu).

Published Online: March 25, 2020. doi:10.1001/jamacardio.2020.0322

Conflict of Interest Disclosure: None reported.

References
1.
Huston  JH, Maron  BA, French  J,  et al Association of mild echocardiographic pulmonary hypertension with mortality and right ventricular function.  JAMA Cardiol. 2019;4(11):1112-1121. doi:10.1001/jamacardio.2019.3345PubMedGoogle ScholarCrossref
2.
Mehmood  M.  Right ventricular-pulmonary artery coupling—let’s not lose the forest for the trees.  JAMA Cardiol. 2019;4(2):188. doi:10.1001/jamacardio.2018.4482PubMedGoogle ScholarCrossref
3.
Mehmood  M.  Letter by Mehmood regarding article, “Validation of the Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure Ratio for the Assessment of Right Ventricular-Arterial Coupling in Severe Pulmonary Hypertension.”  Circ Cardiovasc Imaging. 2019;12(11):e010002. doi:10.1161/CIRCIMAGING.119.010002PubMedGoogle Scholar
4.
Mehmood  M, Biederman  RWW, Markert  RJ, McCarthy  MC, Tchorz  KM.  Right heart function in critically ill patients at risk for acute right heart failure: a description of right ventricular-pulmonary arterial coupling, ejection fraction and pulmonary artery pulsatility index.  Heart Lung Circ. Published online June 20, 2019. doi:10.1016/j.hlc.2019.05.186PubMedGoogle Scholar
5.
Porter  TR, Shillcutt  SK, Adams  MS,  et al.  Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography.  J Am Soc Echocardiogr. 2015;28(1):40-56. doi:10.1016/j.echo.2014.09.009PubMedGoogle ScholarCrossref
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