Diagnostic and prognostic value of echocardiography in pulmonary hypertension: an umbrella review of systematic reviews and meta-analyses

Abstract

Background The role of echocardiography in the diagnostic and prognostic assessment of pulmonary hypertension (PH) has been widely studied recently. However, these findings have not undergone normative evaluation and may provide confusing evidence for clinicians. To evaluate and summarize existing evidence, we performed an umbrella review. Methods Systematic reviews and meta-analyses were searched in PubMed, Embase, Web of Science, and Cochrane Library from inception to September 4, 2022. The methodological quality of the included studies was assessed using Assessment of Multiple Systematic Reviews (AMSTAR), and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the quality of evidence. Results Thirteen meta-analyses (nine diagnostic and four prognostic studies) were included after searching four databases. The methodological quality of the included studies was rated as high (62%) or moderate (38%) by AMSTAR. The thirteen included meta-analyses involved a total of 28 outcome measures. The quality of evidence for these outcomes were high (7%), moderate (29%), low (39%), and very low (25%) using GRADE methodology. In the detection of PH, the sensitivity of systolic pulmonary arterial pressure is 0.85–0.88, and the sensitivity and specificity of right ventricular outflow tract acceleration time are 0.84. Pericardial effusion, right atrial area, and tricuspid annulus systolic displacement provide prognostic value in patients with pulmonary arterial hypertension with hazard ratios between 1.45 and 1.70. Meanwhile, right ventricular longitudinal strain has independent prognostic value in patients with PH, with a hazard ratio of 2.96–3.67. Conclusion The umbrella review recommends echocardiography for PH detection and prognosis. Systolic pulmonary arterial pressure and right ventricular outflow tract acceleration time can be utilized for detection, while several factors including pericardial effusion, right atrial area, tricuspid annular systolic displacement, and right ventricular longitudinal strain have demonstrated prognostic significance. Trial registration PROSPERO (CRD42022356091), https://www.crd.york.ac.uk/prospero/.

The Role of Echocardiography in the Diagnosis and Prognosis of Pulmonary Hypertension

“…Previous studies have demonstrated the strong relationship of RVOT-AT with PASP, independent of TR severity [29]. According to a recent meta-analysis RVOT-AT was highly correlated with PASP values [26]. Another meta-analysis of 21 studies and 1280 patients showed adequately high pooled sensitivity [0.84 (95% CI: 0.75, 0.90)] and specificity [0.84 (95% CI: 0.78, 0.89)] of RVOT-AT to diagnose PH [30].…”

“…An umbrella meta-analysis documented the high sensitivity of echocardiographybased PASP calculation to diagnose PH [26]. However, the included studies showed a high heterogeneity, attributed mainly to the different ways of PASP calculation.…”

“…TAPSE/PASP ratio serves as a non-invasive metric for assessing RVarterial coupling and is influenced by RV diastolic stiffness, particularly in cases of severe PH [49]. The TAPSE/PASP ratio is highlighted as a significant prognostic factor in the assessment of PH, with thresholds of 0.32 mm/mmHg and 0.19 mm/mmHg, distinguishing high, intermediate, and low mortality risk, respectively, as acknowledged in the 2022 ESC guidelines [3,26,49]. A retrospective study of 677 patients with PAH demonstrated that improvement in the TAPSE/PASP ratio under targeted therapies is associated with a low-risk status and a significant reduction in PVR [50].…”

“…Indicators of RV myocardial deformation, such as RV strain and strain rate index, are pivotal in gauging the severity of PH, but also for prognosis. Based on accumulated evidence, a RVLS evaluation (≥−19%) stands out as a crucial predictor of all-cause mortality [37,62,80,81] and its prognostic significance has been extensively highlighted [26]. Even more, RV strain above −15% (both global and free wall in absolute values) serves as an indicator of the poorer survival [60].…”

Echocardiography as a Vital Tool in Assessing Shock: A Comprehensive Review

“…Furthermore, echocardiography is pivotal in both diagnosis and prognosis in the context of pulmonary hypertension (PH). Various echocardiographic parameters, including right ventricular ejection fraction, tricuspid annular plane systolic excursion (TAPSE), and RV strain measured by speckle tracking echocardiography, have been identified as valuable prognostic markers for PH patients, reflecting disease severity and predicting outcomes [ 23 ]. Figure 1 shows the role of echocardiography in assessing shock.…”