The Growing Role of Echocardiography in Pulmonary Arterial Hypertension Risk Stratification: The Missing Piece

Abstract

Pulmonary arterial hypertension (PAH) is a rare, progressive disease with a poor prognosis. The pathophysiologic model is mainly characterized by an afterload mismatch in which an increased right ventricle afterload, driven by increased pulmonary vascular resistance (PVR), leads to right heart failure. International guidelines recommend optimization of treatment based on regular risk assessments to achieve or maintain a low-risk status. Current risk scores are based on a multi-modality approach, including demographic, clinical, functional, exercise, laboratory, and hemodynamic parameters, which lack significant echocardiographic parameters. The originality of echocardiography relies on the opportunity to assess in a non-invasive way a physiologically meaningful combination of easy to measure variables tightly related to right ventricle adaptation/maladaptation to increased afterload, the main determinant of a patient’s prognosis. Echo-derived morphological and functional parameters have been investigated in PAH, proving to have prognostic relevance. Different therapeutic strategies proved to have different effects in reducing PVR. An upfront combination of drugs, including a parenteral prostacyclin, has shown to be associated with right heart reverse remodeling in a greater proportion of patients than other treatment strategies as a function of PVR reduction. Adding echocardiographic data to current risk scores would allow better identification of right ventricle (RV) adaptation in PAH patients’ follow-up. This additional information would allow better stratification of the patient, leading to optimized and personalized therapeutic management.

Right ventricular free-wall longitudinal speckle tracking strain as a prognostic criterion of adverse outcomes in patients with pulmonary hypertension: a systematic review and meta-analysis

“…ЭхоКГ-исследование предоставляет возможность неинвазивного способа оценки комбинации легко измеряемых переменных, тесно связанных с адаптацией/дезадаптацией ПЖ к повышенной постнагрузке, являющихся основной детерминантой прогноза пациента [50]. По результатам выполненного метаанализа при увеличении на 1% RV FW LS отмечается возрастание средневзвешенного риска смертности от всех причин на 14% (p<0,00001), а также средневзвешенного риска неблагоприятного исхода или событий, вызванных ЛГ (комбинированная конечная точка), на 14% (p<0,0001).…”

Reliability of echocardiographic parameters of the systemic right ventricle systolic function: A prospective multicentre study

“…Nevertheless, only the TAPSE correlated with peak VO2. In various pathologies affecting the RV, such as pulmonary hypertension, TAPSE has been the most popular measure used as a surrogate for RV longitudinal systolic function, with a high proven prognostic significance [40]. Despite being a load-dependent and angle-dependent parameter reflecting mainly the lateral wall longitudinal motion, the TAPSE's widespread use is also due to its simplicity of acquisition, and its high reproducibility with low inter-operator variability [41].…”

Echocardiography in Pulmonary Arterial Hypertension: Is It Time to Reconsider Its Prognostic Utility?

“…The problem lies in the fact that the majority of these echo indices has been prognostically evaluated only by small, single-center studies, and there has not been any systemic evaluation of the RV function along with the other parameters of clinical scores. A large prospective cohort study that will simultaneously assess a wide range of echocardiographic, but also clinical, laboratory, and hemodynamic indices, is needed in order to better incorporate echocardiography in PAH risk stratification [84].…”