Peripheral Venous Pressure-Assisted Exercise Stress Echocardiography in the Evaluation of Pulmonary Hypertension During Exercise in Patients With Suspected Heart Failure With Preserved Ejection Fraction

Abstract

Background: Identification of elevated pulmonary artery (PA) pressures during exercise may provide diagnostic, prognostic, and therapeutic implications in heart failure with preserved ejection fraction. Although widely performed, exercise stress echocardiography may underestimate true PA pressures due to the difficulty in estimating right atrial pressure (RAP) during exercise. We hypothesized that peripheral venous pressure (PVP) could allow for reliable estimation of RAP, and thus PA pressures during exercise stress echocardiography. Methods: In protocol 1, we investigated the accuracy of PVP compared with simultaneously measured RAP at rest and during exercise right heart catheterization in 19 subjects. In protocol 2, we examined whether the addition of PVP to Doppler exercise echocardiography (tricuspid regurgitant velocity) would increase the ability to identify exercise-induced pulmonary hypertension compared with inferior vena cava-based RAP estimation in 60 patients with dyspnea. Results: In protocol 1, PVP was strongly correlated with simultaneously measured RAP at rest and during exercise ( r =0.77 and 0.90), with little overestimation of invasively measured RAP (bias 3.4 mm Hg at rest and 1.7 mm Hg during exercise). In protocol 2, PVP increased dramatically during exercise echocardiography (14±5 mm Hg) while an increase in inferior vena cava-based RAP was modest (6±4 mm Hg). Exercise PA pressures calculated from PVP and tricuspid regurgitant velocity were significantly higher than those estimated from inferior vena cava and the use of PVP increased the proportion of patients with exercise-induced pulmonary hypertension from 40% to 68%. Conclusions: PVP may prevent underestimation of PA pressures during exercise echocardiography and could be a preferred approach to identify exercise-induced pulmonary hypertension in patients with suspected heart failure with preserved ejection fraction.

Disproportionate exercise‐induced pulmonary hypertension in relation to cardiac output in heart failure with preserved ejection fraction: a non‐invasive echocardiographic study

“…PASP was calculated as 4 × (the highest averaged TR velocity) 2 + estimated right atrial pressure (RAP). The RAP was estimated from the diameter of the inferior vena cava (IVC) and its respiratory change at rest and during exercise, coded as 3 mmHg (IVC diameter <2.1 cm with >50% respiratory collapse), 8 mmHg (borderline cases who did not meet criteria indicating either 3 or 15 mmHg), 15 mmHg (IVC diameter >2.1 cm with <50% respiratory collapse) 20 . The mPAP was calculated as 0.61 × PASP + 2 21 .…”

“…The RAP was estimated from the diameter of the inferior vena cava (IVC) and its respiratory change at rest and during exercise, coded as 3 mmHg (IVC diameter <2.1 cm with >50% respiratory collapse), 8 mmHg (borderline cases who did not meet criteria indicating either 3 or 15 mmHg), 15 mmHg (IVC diameter >2.1 cm with <50% respiratory collapse). 20 The mPAP was calculated as 0.61 × PASP + 2. 21 RV-PA coupling was assessed by TAPSE/PASP and TAPSE/PASP <0.36 was defined as abnormal RV-PA coupling.…”

Exercise Stress Echocardiography in the Diagnostic Evaluation of Heart Failure with Preserved Ejection Fraction

“…Prior studies reported a close relationship between RAP and peripheral venous pressure at rest [ 56 , 57 ]. Our group recently demonstrated that the measurement of peripheral venous pressure may be a reliable alternative to RAP measurement during diastolic stress echocardiography [ 58 ].…”

Peripheral Venous Pressure: An Important but Neglected Contributor to Echocardiographic Estimation of Pulmonary Artery Pressure With Exercise

“…The sensitivity of exercise echocardiography for EIPH is imperfect because the technique underestimates exercise PASP-not just because of the limitations of TR velocity but also because of the shortcomings of our noninvasive approach to measuring RA pressure. Although the pathway to the clinical adoption of PVP measurement is unclear, the study by Yang et al 13 serves as a reminder of the limits of agreement between hemodynamic exercise echocardiography and invasive measurements. Examining the PASP response to increased stroke volume may be the key to earlier diagnosis and intervention in a variety of diseases, including scleroderma 14 and heart failure with preserved ejection fraction.…”

“…In this issue of Circulation: Heart Failure , Yang et al 13 have hypothesized that peripheral venous pressure (PVP) could provide reliable estimation of right arterial pressure (RAP) with exercise, and thus more accurate pulmonary artery pressures during exercise stress echocardiography. They studied this in 2 steps.…”