How Good Is Tricuspid Regurgitation Velocity in Excluding Pulmonary Hypertension in Patients with Left Heart Disease

Abstract

Cocaine causes myocardial injury via multiple mechanisms.Aims: (a) To compare clinical and cardiac magnetic resonance (CMR) characteristics of myocardial injury in cocaine-induced ST elevation myocardial infarction (STEMI) versus our institution's general STEMI population and (b) to examine for evidence of silent myocardial injury in asymptomatic cocaine users.Methods/results: Four patients presented with cocaineinduced ST elevation MI over 12 months. All were males with a mean age of 37 years. Three had thrombotic coronary occlusion requiring repeated thrombus aspiration and one, who received lysis for anterior STEMI at a peripheral hospital, had anterior akinesis with no obvious culprit. Peak troponins were 4124 ± 1226 ng/L (mean ± SEM). CMR demonstrated extensive transmural MI with microvascular obstruction (MVO) in all four (100%: figure). In contrast, MVO was observed in ∼50% of our general STEMI population undergoing CMR. Thrombophilia screen was positive in two out of three of the cocaine-induced STEMIs tested. Zero in eighteen asymptomatic heavy cocaine users had late gadolinium enhancement on CMR to suggest silent myocardial injury.Conclusions: In patients with STEMI attributed to cocaine use, we have observed extensive thrombosis, with a high degree of MVO. The high incidence of prothrombotic abnormalities suggests an interactive effect of cocaine with thrombophilic tendency.Background: Pulmonary hypertension (PH) is defined as mean pulmonary artery pressure (mPAP) >25 mmHg. Patients undergoing cardiac surgery have increased mortality if they have significant PH, defined as systolic pulmonary artery pressure (sPAP) >60 mmHg. Our aim was to see if measurement of tricuspid regurgitant velocity (TRVmax) by Doppler echocardiography can exclude PH.Methods: Patients having a transthoracic echocardiogram (TTE) and right heart catheterisation (RHC) within three days of each other were reviewed. TRVmax < 2.8 m/s was used as a cut-off to exclude PH as recommended by ESC guidelines for PH.Results: From January 2004 to February 2011, 693 patients had RHC before cardiac surgery. Out of these, 159 patients had TTE within three days of RHC and were used for analysis. Prevalence of PH was 51% in this group. TRVmax was measured in 99(62%) out of 159 patients. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for diagnosis of PH (mPAP > 25mmHg) were 66%, 83%, 65% and 84% respectively. Sensitivity, specificity, NPV and PPV for diagnosis of significant PH (sPAP > 60 mmHg) were 80%, 64%, 93% and 36% respectively. TRVmax was not measurable in 60 (38%) patients due to no tricuspid regurgitation (TR) or trace TR. Absent/trace TR had a 50% NPV to exclude diagnosis of PH and 93% NPV to exclude significant PH.Conclusion: TRVmax < 2.8 m/s has a low sensitivity (66%) and NPV (65%) for diagnosis of PH, but high sensitivity (80%) and NPV (93%) to exclude significant PH. Absent/trace TR has low NPV (50%) for diagnosis of PH but high NPV (93%) to exclude significant PH.