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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. Published online March 25, 2020. 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.

Uniform measurement of RV function is important to perform in all patients undergoing echocardiography to adequately frame clinical interpretation of the RVSP. We also agree that reporting of quantitative measures of RV function should be standard in all patients undergoing echocardiography, as recommended by the American Society of Echocardiography.4

Although a large proportion of patients with mildly elevated pressure by echocardiography do not require invasive measurements, in many cases, such information should prompt further assessment of potential etiologies, such as sleep studies, pulmonary function testing, or exercise echocardiography. We recognize that clinical trials in this population will be challenging because of the lower event rates in comparison with patients with more advanced disease. We support careful application of Mehmood’s suggestions to address this challenge: use of echocardiography to monitor therapeutic response in select patients and use of RV-PA coupling as a surrogate end point. A mountain of epidemiologic evidence demonstrates risk among patients with mild PH. We now have to turn our attention to developing strategies for identifying effective interventions for the pulmonary vasculature and the RV in patients with evidence of mild PH.

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Article Information

Corresponding Author: Evan L. Brittain, MD, MSc, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave S, Medical Center East, Ste 5027, Nashville, TN 37232-8802 (evan.brittain@vumc.org).

Published Online: March 25, 2020. doi:10.1001/jamacardio.2020.0325

Conflict of Interest Disclosures: 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.
McLaughlin  VV, Archer  SL, Badesch  DB,  et al; American College of Cardiology Foundation Task Force on Expert Consensus Documents; American Heart Association; American College of Chest Physicians; American Thoracic Society, Inc; Pulmonary Hypertension Association.  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 developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association.  J Am Coll Cardiol. 2009;53(17):1573-1619. doi:10.1016/j.jacc.2009.01.004PubMedGoogle ScholarCrossref
3.
Shah  AM, Cikes  M, Prasad  N,  et al; PARAGON-HF Investigators.  Echocardiographic features of patients with heart failure and preserved left ventricular ejection fraction.  J Am Coll Cardiol. 2019;74(23):2858-2873. doi:10.1016/j.jacc.2019.09.063PubMedGoogle ScholarCrossref
4.
Rudski  LG, Lai  WW, Afilalo  J,  et al.  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 Echocardiogr. 2010;23(7):685-713. doi:10.1016/j.echo.2010.05.010PubMedGoogle ScholarCrossref
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