Provider Recognition and Response to Echocardiographic Findings Indicating Pulmonary Hypertension in the Veterans Affairs Medical Center Population

Abstract

PH occurs alone or in association with many disorders. Many patients with transthoracic echocardiography (TTE) findings suggesting PH never receive additional evaluation. Patient characteristics and echocardiographic data associated with increased recognition of PH have not been fully evaluated. We evaluated TTE reports at the Cincinnati Veterans Affairs Medical Center from 2005 to 2006 retrospectively for findings highly indicative of PH: Estimated systolic pulmonary artery pressure (sPAP) ≥40 mmHg, increased right atrial or right ventricular (RV) size, or reduced RV function. Only patients with left ventricular ejection fraction (LVEF) ≥50% and no known diagnosis of PH were included. Patient characteristics, TTE findings, provider recognition rates, and subsequent referral for additional evaluation were assessed. A total of 227 of 3,960 (5.7%) TTE reports revealed findings indicating possible PH. Providers acknowledged possible PH in 53 (23.4%) reports. Recognized PH was predicted by increased RV size (odds ratio (OR) = 5.07, P < 0.001), increased right atrial dimension (OR = 6.45, P < 0.001), decreased RV function (OR = 8.86, P < 0.001), and increased PAP (OR = 1.04 corresponding to each unit increase of PAP, P < 0.01). Patients with comorbid obstructive sleep apnea (OSA), interstitial lung disease, and dyspnea were also more likely to be recognized (OR = 3.63, P = 0.021; OR = 10.98, P = 0.004; OR = 2.39, P = 0.007, respectively). The 12-month mortality rate for recognized patients, 11.3% (7/53), was lower than for unrecognized patients, 25.3% (44/174; P = 0.03). Providers recognized less than one in four patients with echocardiographic evidence suggesting PH. Echocardiography reports revealing higher PAP and right heart dilation and dysfunction are associated with increased acknowledgement of possible PH.

Multispecialty pulmonary hypertension clinic in the VA

“…In a prior study of veterans with abnormally high PAPs on echocardiogram, only a small fraction (5/227, 2.2%) ultimately underwent RHC. 5 In another study of veterans with a pulmonary artery systolic pressure ≥ 60 mmHg on echocardiogram, only a minority underwent further diagnostic testing such as pulmonary function testing with diffusion capacity measurement, V/Q scan or chest computed tomography angiography, or RHC. 4 Referral to a multidisciplinary PH clinic resulted in completion of guideline-recommended assessments 8 in the majority of our patients with PH.…”

“…However, despite evidence of PH being a frequent finding on echocardiograms, studies have shown that PH is often mis- or underdiagnosed in both veterans 4 , 5 and non-veterans. 6 To address this issue at our VA medical center, we undertook efforts to establish a referral clinic for veterans with known or suspected PH.…”

Derivation of a Screening Tool to Identify Patients with Right Ventricular Dysfunction or Tricuspid Regurgitation after Negative Computerized Tomographic Pulmonary Angiography of the Chest

“…[13][14][15][16][17] However, although PH has major implications on morbidity and mortality, recent studies suggest that it is frequently overlooked and underrecognized. 18,19 Early diagnosis and treatment improve outcomes. Since RV function determines functional status, exercise capacity, and outcomes in PH, and since RV dysfunction is commonly observed in PH patients, we hypothesized that a substantial portion of patients with persistent dyspnea, despite negative CTPA for PE, have unrecognized RV dysfunction or overload on echocardiography that contributes to persistent symptoms and CTPA recidivism.…”