inn a curacy of eco for pah chest 2011

8/4/2019 Inn a Curacy of Eco for PAh Chest 2011

1/8

DOI 10.1378/chest.10-12692011;139;988-993; Prepublished online September 23, 2010;Chest

Stuart RichJonathan D. Rich, Sanjiv J. Shah, Rajiv S. Swamy, Anna Kamp andImplications for Clinical Practice

Patients With Pulmonary Hypertension :Estimates of Pulmonary Artery Pressures inInaccuracy of Doppler Echocardiographic

http://chestjournal.chestpubs.org/content/139/5/988.full.html

services can be found online on the World Wide Web at:The online version of this article, along with updated information and

9.DC1.html

http://chestjournal.chestpubs.org/content/suppl/2011/05/03/chest.10-126Supplemental material related to this article is available at:

ISSN:0012-3692)http://chestjournal.chestpubs.org/site/misc/reprints.xhtml(

written permission of the copyright holder.this article or PDF may be reproduced or distributed without the priorDundee Road, Northbrook, IL 60062. All rights reserved. No part ofCopyright2011by the American College of Chest Physicians, 3300Physicians. It has been published monthly since 1935.

is the official journal of the American College of ChestChest

2011 American College of Chest Physiciansat Rush Univ Med Lib on June 15, 2011chestjournal.chestpubs.orgDownloaded from
http://chestjournal.chestpubs.org/content/139/5/988.full.htmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.htmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.htmlhttp://chestjournal.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.html


2/8

988

CHEST Original ResearchPULMONARY VASCULAR DISEASE

Original Research

Pulmonary hypertension (PH) is a condition asso-ciated with substantial morbidity and mortality.1

The prognosis for patients with PH is generally poorand is closely related to several hemodynamic

variables.2,3 Accurate measurements of hemodynam-ics, including pulmonary artery pressures (PAP), are

critical for both the diagnosis and appropriate man-

agement of individual patients with PH. Right-sided heart catheterization (RHC) remains theaccepted standard approach in determining PAP.4,5

Background: Recent studies suggest that Doppler echocardiography (DE)-based estimates of pul-monary artery systolic pressure (PASP) may not be as accurate as previously believed. We sought

to determine the accuracy of PASP measurements using DE compared with right-sided heartcatheterization (RHC) in patients with pulmonary hypertension (PH).Methods: We compared DE estimates of PASP to invasively measure PASP during RHC in160 consecutive patients with PH (part one). To account for possible changes in hemodynamicsbetween DE and RHC, we then prospectively determined PASP in an additional 23 consecu-tive patients undergoing simultaneous RHC and DE (part two). Bland-Altman analyses wereperformed to evaluate the agreement between RHC and DE measurements of PASP. Accu-racy was predefined as 95% limits of agreement within6 10 mm Hg for PASP estimates.

Results: In part one, there was moderate correlation between DE and RHC measurements ofPASP (r50.68,P, .001). However, using Bland-Altman analysis, the bias for DE estimates ofPASP was 2.2 mm Hg with 95% limits of agreement ranging from 234.2 to 38.6 mm Hg. DE esti-mates of PASP were determined to be inaccurate in 50.6% of patients. In part two, there wasmoderate correlation between DE and RHC measurements of PASP (r50.71,P, .01). However,despite simultaneous DE and RHC measurements, the bias for DE estimates of PASP was 8.0 mm Hg

with 95% limits of agreement ranging from 228.4 to 44.4 mm Hg.Conclusions: DE estimates of PASP are inaccurate in patients with PH and should not be reliedon to make the diagnosis of PH or to follow the efficacy of therapy. CHEST 2011; 139(5):988993

Abbreviations: DE5Doppler echocardiography; IVC5 inferior vena cava; PAP5pulmonary artery pressure;PASP5pulmonary artery systolic pressure; PH5pulmonary hypertension; RAP5right atrial pressure; RHC5right-sidedheart catheterization; RV5 right ventricle; TR5 tricuspid regurgitant

Inaccuracy of Doppler EchocardiographicEstimates of Pulmonary Artery Pressuresin Patients With Pulmonary Hypertension

Implications for Clinical Practice

Jonathan D. Rich, MD; Sanjiv J. Shah, MD; Rajiv S. Swamy, MD; Anna Kamp, MD;and Stuart Rich, MD, FCCP

Manuscript received May 17, 2010; revision accepted August 9,2010.

Affiliations: From the Pritzker School of Medicine Section ofCardiology (Drs J. D. Rich, Swamy, and S. Rich), Department ofMedicine, University of Chicago Medical Center, and theDivision of Cardiology (Dr Shah), Department of Medicine,Northwestern University Feinberg School of Medicine, Chicago, IL;and the Department of Pediatrics (Dr Kamp), University ofMichigan Medical Center, Ann Arbor, MI.Correspondence to: Jonathan D. Rich, MD, University ofChicago, 5841 S Maryland Ave, MC 6080, Chicago, IL 60637;e-mail: [email protected]

2011 American College of Chest Physicians. Reproductionof this article is prohibited without written permission from theAmerican College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).DOI: 10.1378/chest.10-1269

For editorial comment see page 973

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/mailto:[email protected]://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlmailto:[email protected]


3/8

www.chestpubs.org CHEST / 139 / 5 / MAY, 2011 989

catheterization and PH. Hemodynamic measurements obtainedduring the RHC, including right atrial pressure (RAP) and PASP,

were recorded at end expiration. The physicians performing theRHC were blinded to the DE data obtained during the simultane-ous performance of the RHC.

Echocardiography

Two-dimensional transthoracic echocardiography and DE wereperformed using either a Philips Sonos 7500 or IE33 machine

with a 3.2 MHz transducer (Philips Medical Systems; Andover,Massachusetts). Echocardiograms were performed in multiple

views to obtain the optimal appearing TR jet. Patients wereexcluded from the study if no tricuspid regurgitation was presenton DE or if the TR jet was insufficient to estimate the PASP. Afteracquiring the necessary images, the TR jet velocities were mea-sured, and estimated PASPs were determined using the modifiedBernoulli equation in conjunction with an echocardiographicestimation of RAP. Echocardiographic estimation of RAP wasperformed based on inferior vena cava (IVC) size and collaps-ibility, according to the following established criteria14: RAP wasestimated to be 0 to 5 mm Hg when the IVC diameter was,17 mmand .50% collapsibility; 5 to 10 mm Hg when the IVC diameter

was ,17 mm and ,50% collapsibility; 10 to 15 mm Hg when

the IVC diameter was . 17 mm and , 50% collapsibility; and15 to 20 mm Hg when the IVC diameter was .17 mm withabsence of any collapsibility. All echocardiographic and DE studies

were performed by an experienced, cert ified sonographer. Forthe simultaneous DE and RHC part of the study, a single,experienced, certified sonographer performed all the DE studiesto exclude the possibility of intersonographer variability. Interpre-tations of echocardiographic and DE measurements were per-formed only by physicians experienced with and board certifiedin echocardiography. The sonographers and echocardiographyphysicians were all blinded to the RHC data in all parts of thestudy.

Statistics

Descriptive statistics were described using mean (SD) forcontinuous variables and number (%) for categorical variables.Correlation coefficients between RHC- and DE-derived hemody-namics were calculated using the Pearson correlation method.However, correlation coefficients are often misleading and shouldnot be used to assess the agreement or interchangeability betweentwo different modalities. It is generally expected that when twodifferent modalities (eg, DE and RHC) are used to assess a par-ticular variable (eg, PASP), with each modality designed to mea-sure the same variable, there will be a strong correlation, especiallyif there is a wide range of values tested. A high correlation,however, does not automatically imply that there is good agree-ment between the two methods. Therefore, Bland-Altman analy-ses, which plot the difference between two modalities against

their mean, are necessary to truly evaluate agreement betweentwo methods. For these reasons, we used Bland-Altman analy-ses to evaluate the agreement between DE estimates of PASPand RAP, respectively, with those same values as determined byRHC.15 To interpret the results of the Bland-Altman analysesclinically, DE estimates of PASP would be considered accurateif the differences within the 95% limits of agreement betweenDE and RHC measurements of PASP were small and not consid-ered clinically relevant. Alternatively, it would be unacceptableto consider DE estimates of PASP as accurate compared withRHC measurements of PASP if the 95% limits of agreement

were large and thought to be of clinical relevance. Accuracy waspredefined as 95% limits of agreement within 610 mm Hg forPASP estimates and 62.5 mm Hg for RAP estimates. Statistical

However, because of its widespread availability andease of use in the outpatient setting, Doppler echocar-diography (DE) is implemented with increasingfrequency as a tool for determining PAP, both forestablishing a diagnosis and for monitoring treat-ment. In fact, DE has replaced RHC for determininghemodynamics in a National Institutes of Health-sponsored randomized clinical trial in patients with

PH.6 Although DE estimates of PAP have beenshown to correlate with RHC measurements ofPAP,7-9 the reliability of DE to accurately measure PAPin patients with PH is not clear. Studies have sug-gested that DE estimates of PAP may not be as accu-rate as previously believed,10-12 although these studiesdid not compare simultaneous measurements of PAPby DE obtained during RHC, and, thus, fluctuationsin PAP at different points in time may have affectedtheir findings.13

As a large referral center for patients with PH, theUniversity of Chicago has become increasingly con-

cerned about the accuracy of measurements of PAPmade solely with DE and, as a consequence, the sub-sequent inappropriate diagnoses and managementdecisions that occur. Thus, we conducted the presentstudy to evaluate the accuracy of DE as a noninvasivediagnostic tool in patients with PH.

Materials and Methods

The institutional review board at the University of Chicago(approval number 15271A) approved the conduct of this study,and all patients provided written consent prior to enrollment. Thisstudy was conducted in two parts.

Part One

We prospectively identified 160 consecutive patients referred forpresumed PH and who subsequently underwent both RHC andDE between April 2005 and February 2008. Eligibility criteriaincluded the following: (1) RHC and DE occurred within 30 days ofeach other, (2) no change in patient clinical status or medicationsoccurred during this 30-day interval, and (3) a measurable tricuspidregurgitant (TR) jet, necessary for DE estimations of pulmonaryartery systolic pressure (PASP), was present on the DE study.

Part Two

To address the possibility that variations in hemodynamics occur-ring during the 30-day interval between RHC and DE may affectour findings, we prospectively enrolled an additional 23 consecu-tive patients referred to our PH specialists for RHC as part of anevaluation of PH. DE imaging was performed on each of thesepatients in the cardiac catheterization laboratory simultaneousto the invasive hemodynamic measurements made during theRHC.

Right-Sided Heart Catheterization

All RHC measurements made during the study were per-formed by one of two physicians experienced in both cardiac

http://www.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://www.chestpubs.org/


4/8

990 Original Research

the echocardiographic estimate of RAP (r5 0.38,P, .001). However, Bland-Altman analysis revealed abias of23.3 mm Hg and 95% limits of agreementranging from215.6 to 8.9 mm Hg (Fig 2).

Using the predefined definition of an inaccurateDE estimation of PASP as 6 10 mm Hg differentfrom PASP measured during RHC, we found that

DE was inaccurate 50.6% (81/160) of the time. Wheninaccurate, DE overestimated PASP by.10 mm Hgin 40.7% (33/81) of cases and underestimated PASPby.10 mm Hg in 59.3% (48/81) of cases. Using thepredefined definition of an inaccurate echocardio-graphic estimate of RAP as 62.5 mm Hg differentfrom RAP measured during RHC, we found thatechocardiography was inaccurate in 58.7% (64/109)of the cases. When inaccurate, echocardiography over-estimated RAP by.2.5 mm Hg in 64.1% (41/64) ofcases and underestimated RAP by.2.5 mm Hg in35.9% (23/64) of the cases.

In part two of the study, there was a moderatelystrong correlation between PASP determinedduring RHC and estimated PASP using DE

analyses were performed using Stata 10.1 (StataCorp; CollegeStation, Texas).

Results

The baseline characteristics of the patients in thisstudy can be seen in Table 1. The majority of patients

were women who received a diagnosis of World HealthOrganization group 1 PAH, although patients withother causes of PH were also included in this study.The hemodynamics obtained during RHC and DEare summarized in Table 2. A wide range of PASP(20 mm Hg to 120 mm Hg) and RAP (1 mm Hg to35 mm Hg) during RHC was observed. In a smallminority of the patients, the RHC assessment of hemo-dynamics excluded the presence of PH, which wasdefined as a mean PAP25 mm Hg.

In part one of the study, there was a moderatelystrong correlation between PASP determined dur-ing RHC and estimated PASP using DE (r50.68,P, .001). However, using Bland-Altman analyses, themean bias for DE estimates of PASP was 2.2 mm Hg

with 95% limits of agreement ranging from234.2 to38.6 mm Hg (Fig 1). Thus, even after excludingthe 5% of patients with the most discrepant valuesbetween DE and RHC measurement of PASP, DEunderestimated PASP as measured by RHC by asmuch as 34.2 mm Hg and overestimated it by as muchas 38.6 mm Hg. When we analyzed the data accordingto subgroups of patients based on the different causesof their PH (as listed in Table 1), we did not find DEestimates of PASP to be any more or less accurate inany of the individual subgroups. There was also a mildcorrelation between RAP measured during RHC and

Table 1Patient Demographics and Causes of PH

Variable Part One (n5160) Part Two (n523)

Age, mean6SD, y 53.4614.5 52.8614.2Female 78.1 (125) 78.3 (18)PH present 96.7 (155) 91.3 (21)PH diagnoses

WHO group 1 PH 72.3 (112) 76.2 (16)IPAH 37.4 (58) 47.6 (10)

CVD 19.4 (30) 19.0 (4)CHD 7.7 (12) 6.3 (1)Portal hypertension 7.7 (12) 6.3 (1)

Non-WHO group 1 PH 27.7 (43) 23.8 (5)PVH 14.2 (22) 9.5 (2)Lung disease 7.1 (11) 6.3 (1)CTEPH 3.2 (5) 0 (0)Sarcoid 3.2 (5) 9.1 (2)

Data are presented as % (No.) unless otherwise indicated.CHD5congenital heart disease; CTEPH5 chronic thromboem-bolic pulmonary hypertension; CVD5 collagen vascular disease;IPAH5 idiopathic pulmonary arterial hypertension; PH5pulmonaryhypertension; PVH5pulmonary venous hypertension; WHO5WorldHealth Organization.

Table 2Patient Hemodynamics Accordingto RHC and DE

Variable RHC, mm Hg DE, mm Hg

Part 1 (n5160)PASP 79.3621.0 77.1624.2RAP (n5109) 8.865.7 12.265.0

Part 2 (n523)PASP 65.5626.1 56.9620.5

RAP 7.16

4.7 7.26

3.6Data are presented as mean6SD. DE5Doppler echocardiography;PASP5pulmonary artery systolic pressure; RAP5right atrial pressure;RHC5 right-sided heart catheterization.

Figure 1. Bland-Altman analysis demonstrating a lack of agree-ment between DE estimates of pulmonary artery systolic pressure(PASP) and PASP determined during RHC (solid line), as high-lighted by the 95% limits of agreement, ranging from 234.2 mm Hgto 38.6 mm Hg (dashed lines). Larger circles represent identicalobservations among multiple patients. The inaccuracy of DE estimatesof PASP is particularly apparent at higher PASP. DE5Dopplerechocardiography; RHC5right-sided heart catheterization.

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/


5/8


common misconception is in part what led Blandand Altman to publish their sentinel paper describ-ing their method of determining the agreementbetween two methods of clinical measurement.15

Our findings in this study confirm those found inprevious studies that a moderate correlation does existbetween DE and RHC measurements of PASP.7,8,17However, when Bland-Altman analyses are per-

formed to assess the agreement between DE andRHC, the accepted reference standard by which tomeasure hemodynamics, we find that DE is inaccu-rate .50% of the time. Underestimations and over-estimations of PASP were both common occurrencesusing DE, although DE was somewhat more likely tounderestimate PASP, consistent with other studiesusing DE estimates of hemodynamics.10 Performanceof simultaneous DE and RHC measurements of PASPdid not alter the findings that DE estimates of PASPin patients with PH are inaccurate. The extent ofthe imprecision of DE estimates of PASP compared

with RHC-based estimates appeared greater at higherPASPs (Fig 1). This confusion over the interchange-ability between DE and RHC can lead to inappropri-ate diagnoses and mismanagement of patients withPH.10

Considered a rare disease, the first published inci-dence of primary PH confirmed by RHC was reportedin 199620 and prevalence was estimated at approxi-mately one per 1 million, although the prevalence ofPH from all causes was felt to be considerably higher.21Recently, hospital discharge data from the Centers forMedicare and Medicaid Services reported 301,400

discharges of patients with a presumed diagnosis ofPH in 1997, with a dramatic increase in this figure to456,500 in 2005.22 The importance of this remarkablefinding is magnified by the fact that physicians com-monly use DE in place of RHC in the diagnosis andassessment of PH, which is likely contributing to thisincrease in PH diagnoses.23 In addition, we havefound that DE is too unreliable to detect changes inPASP of 10 mm Hg, which is the change that occursfrom pulmonary vasodilator therapies.24

The increase in the number of patients carrying apresumed diagnosis of PH has important implica-

tions. The management of the patient with PH isextremely expensive. For example, the annual cost oftherapy with the endothelin receptor antagonist,bosentan, a commonly used first-line therapy to treatPH, is $36,208.4,5,25 When coupled with the additionalexpenses of frequent office visits and other testingmodalities, the diagnosis of PH becomes very costly.The problem of using DE as an efficacy measure intreating PH patients is underscored by a recent regis-try on the practices of physicians treating patients

with PH, which reported that one-third of patientswere receiving combination therapies that have not

(r5 0.71, P, .01). However, using Bland-Altmananalysis of the simultaneous RHC and DE, themean bias was 8.0 mm Hg and 95% limits of agree-ment ranged from228.4 mm Hg to 44.4 mm Hg.

Discussion

In this study of patients with PH, we found thatPASP measurements as estimated by DE were inac-

curate when compared with PASP determined by RHC.This suggests that DE should not be used to diagnosePH or to determine the response to medical therapyin patients with PH.

The development of quantitative Doppler measure-ments from TR jets observed on echocardiogramshas had a dramatic impact on the clinical diagnosis ofPH. In 1984, Yock et al16 reported that quantitationof the regurgitant tricuspid jet from Doppler mea-surements to estimate PASP correlated significantly

with PASP measured at RHC in 20 patients. Severalsimilar observations were published subsequently, from

which it became widely accepted that DE providesan accurate, noninvasive measurement of PASP.7-9,17As a result, and because of the relative ease andnoninvasive nature of echocardiography, DE has nowreplaced RHC as the method of choice to makehemodynamic measurements in several clinical stud-ies of patients with PH18,19 and even in a NationalInstitutes of Health-sponsored randomized clinicaltrial.6 However, it has been shown that a strong cor-relation between two methods should not be inter-preted as indicating an accurate and clinically reliableinterchangeability of those same two methods. This

Figure 2. A wide range of variation and lack of agreement existsbetween echocardiographic estimates of right atrial pressure(RAP) compared with RAP measured directly during RHC (solidline), as highlighted by the wide 95% limits of agreement, rangingfrom 15.6 mm Hg to 8.9 mm Hg (dashed lines). Larger circlesrepresent identical observations among multiple patients. Theinaccuracy of the echocardiographic estimates of RAP appears

to be greater at higher RAPs. Echo 5 echocardiography. SeeFigure 1 legend for expansion of other abbreviations.

http://www.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://www.chestpubs.org/


6/8

992 Original Research

of echocardiography combined with DE as an initialscreening test is warranted.30 Echocardiographyshould thus be considered complementary to RHCin the evaluation of patients with PH.4,5

Conclusions

In conclusion, we have confirmed that DE esti-mates of PASP in patients with PH are inaccuratecompared with RHC-based measurements. Echocar-diography is a useful screening tool for suspectedPH, but the definitive diagnosis and follow-up hemo-dynamic assessments should be performed with RHC.In particular, DE estimates of PASP should not berelied on when making management decisions.

Acknowledgments

Author contributions: Dr J. D. Rich: contributed to the designof the study, data collection and analyses, and drafting of themanuscript.

Dr Shah: contributed to data collection and analyses and revisionsto the manuscript.Dr Swamy: contributed to data collection and revisions to themanuscript.Dr Kamp: contributed to data collection and revisions to themanuscript.Dr S. Rich: contributed to the design of the study, data collectionand analyses, and revisions to the manuscript.Financial/nonfinancial disclosures: The authors have reportedto CHEST that no potential conflicts of interest exist with anycompanies/organizations whose products or services may be dis-cussed in this article.

References

1. Thenappan T, Shah SJ, Rich S, Gomberg-Maitland M.A USA-based registry for pulmonary arterial hypertension:1982-2006. Eur Respir J. 2007;30(6):1103-1110.

2. DAlonzo GE, Barst RJ, Ayres SM, et al. Survival in patientswith primary pulmonary hypertension. Results from a nationalprospective registry.Ann Intern Med. 1991;115(5):343-349.

3. McLaughlin VV, Shillington A, Rich S. Survival in primarypulmonary hypertension: the impact of epoprostenol therapy.Circulation. 2002;106(12):1477-1482.

4. McLaughlin VV, Archer SL, Badesch DB, et al; ACCF/AHA.ACCF/AHA 2009 expert consensus document on pulmonaryhypertension: a report of the American College of CardiologyFoundation Task Force on Expert Consensus Documents andthe American Heart Association: developed in collaboration

with the American College of Chest Physicians, American

Thoracic Society, Inc., and the Pulmonary HypertensionAssociation. Circulation. 2009;119(16):2250-2294.

5. Gali N, Hoeper MM, Humbert M, et al; Authors/Task ForceMembers; ESC Committee for Practice Guidelines (CPG);Document Reviewers. Guidelines for the diagnosis and treat-ment of pulmonary hypertension: The Task Force for theDiagnosis and Treatment of Pulmonary Hypertension of theEuropean Society of Cardiology (ESC) and the EuropeanRespiratory Society (ERS), endorsed by the InternationalSociety of Heart and Lung Transplantation (ISHLT).Eur Heart J. 2009;30(20):2493-2537.

6. National Institutes of Health Clinical Center. Pulmonaryhypertension, hypoxia and sickle cell disease. NCT00495638.ClinicalTrials.gov. Bethesda, MD: National Institutes of Health;

been shown to be effective.26 Unfortunately, physi-cians are frequently unaware of the costs of suchmedical tests and therapies.27 It is thus of paramountimportance that accurate measurements of hemody-namics be performed in patients when making diag-nostic and therapeutic decisions.

There appear to be several identifiable potentialpitfalls that can explain the inaccuracy of using DE to

determine PASP. Whereas PASP is measured directlyduring RHC, estimation of PASP using DE requiresa two-step process, with each step having its owninherent imprecision. The pressure gradient betweenthe right ventricle (RV) and right atrium during sys-tole must be determined, and this requires the patientto have tricuspid regurgitation. If tricuspid regur-gitation is present, a TR Doppler signal suitable forperforming a precise measurement of the peak TR

velocity must also be present. Unfortunately, there issubstantial variability in the quality of the TR jet inpatients with PH, which contributes to imprecise

determinations of the peak TR velocity.10 Also, themodified Bernoulli equation assumes a perfect, paral-lel alignment between the Doppler beam and the TR

jet. Failure to correct for the angle between the Dop-pler beam and TR jet can result in an inaccuratedetermination of the peak TR velocity used to deter-mine the pressure gradient. Even when the TR jet isof sufficient quality and the Doppler beam is alignedoptimally, the presence of severe tricuspid regurgi-tation, a common finding in patients with PH, mayresult in an underestimation of this pressure gradient.10Determination of this pressure gradient between the

RV and right atrium is followed by the addition of anechocardiographic estimate of RAP, using the param-eters of IVC size and collapsibility as a surrogate forthe directly measured RAP. However, a recent studyhas shown that RAP estimates using echocardiographyare relatively imprecise.28 We, too, have confirmed inthe present study that echocardiographic estimatesof RAP are inaccurate when compared with RAPmeasured during RHC (Fig 2). Because of the manysteps involved in the noninvasive estimation of PASP,each with its own inherent limitations, it is not par-ticularly surprising that we have found using DE

estimates of PASP to be an unreliable method inpatients with PH.

Despite the unreliability of DE to accurately deter-mine PASP, echocardiography remains a criticallyimportant tool in patients with PH by providing anassessment of various indices of RV size and function,many of which have proven to be independent pre-dictors of outcomes in patients with PH.29 In addi-tion, echocardiography is invaluable for identifyingmany of the conditions that can cause secondary PH.Because DE estimates of PASP do correlate mod-erately well with PASP determined by RHC, the use

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/


7/8


2007. http://clinicaltrials.gov/ct2/show/NCT00495638. UpdatedMarch 5, 2011.

7. Berger M, Haimowitz A, Van Tosh A, Berdoff RL, Goldberg E.Quantitative assessment of pulmonary hypertension inpatients with tricuspid regurgitation using continuous waveDoppler ultrasound.J Am Coll Cardiol. 1985;6(2):359-365.

8. Hecht SR, Berger M, Berdoff RL, Van Tosh A, Stimola JM.Use of continuous-wave Doppler ultrasound to evaluate andmanage primary pulmonary hypertension. Chest. 1986;90(5):781-783.

9. Selimovic N, Rundqvist B, Bergh CH, et al. Assessment ofpulmonary vascular resistance by Doppler echocardiographyin patients with pulmonary arterial hypertension. J Heart

Lung Transplant. 2007;26(9):927-934.10. Fisher MR, Forfia PR, Chamera E, et al. Accuracy of

Doppler echocardiography in the hemodynamic assessmentof pulmonary hypertension.Am J Respir Crit Care Med. 2009;179(7):615-621.

11. Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardio-graphic assessment of pulmonary hypertension in patients

with advanced lung disease. Am J Respir Crit Care Med.2003;167(5):735-740.

12. Krowka MJ, Swanson KL, Frantz RP, McGoon MD,Wiesner RH. Portopulmonary hypertension: results from a

10-year screening algorithm. Hepatology. 2006;44(6):1502-1510.13. Rich S, DAlonzo GE, Dantzker DR, Levy PS. Magnitude

and implications of spontaneous hemodynamic variability inprimary pulmonary hypertension.Am J Cardiol. 1985;55(1):159-163.

14. Lang RM, Bierig M, Devereux RB, et al; Chamber Quan-tification Writing Group; American Society of Echocardio-graphys Guidelines and Standards Committee; EuropeanAssociation of Echocardiography. Recommendations forchamber quantification: a report from the American Societyof Echocardiographys Guidelines and Standards Committeeand the Chamber Quantification Writing Group, developedin conjunction with the European Association of Echocardio-graphy, a branch of the European Society of Cardiology.J AmSoc Echocardiogr. 2005;18(12):1440-1463.

15. Bland JM, Altman DG. Statistical methods for assessingagreement between two methods of clinical measurement.

Lancet. 1986;1(8476):307-310.16. Yock PG, Popp RL. Noninvasive estimation of right ventricu-

lar systolic pressure by Doppler ultrasound in patients withtricuspid regurgitation. Circulation. 1984;70(4):657-662.

17. Currie PJ, Seward JB, Chan KL, et al. Continuous waveDoppler determination of right ventricular pressure: a simul-taneous Doppler-catheterization study in 127 patients.J AmColl Cardiol. 1985;6(4):750-756.

18. Sastry BK, Narasimhan C, Reddy NK, Raju BS. Clinicalefficacy of sildenafil in primary pulmonary hypertension: arandomized, placebo-controlled, double-blind, crossoverstudy.J Am Coll Cardiol. 2004;43(7):1149-1153.

19. Hoeper MM, Markevych I, Spiekerkoetter E, Welte T,Niedermeyer J. Goal-oriented treatment and combination

therapy for pulmonary arterial hypertension. Eur Respir J.2005;26(5):858-863.

20. Abenhaim L, Moride Y, Brenot F, et al; International PrimaryPulmonary Hypertension Study Group. Appetite-suppressantdrugs and the risk of primary pulmonary hypertension.

N Engl J Med. 1996;335(9):609-616.21. Humbert M, Sitbon O, Chaouat A, et al. Pulmonary arterial

hypertension in France: results from a national registry.Am JRespir Crit Care Med. 2006;173(9):1023-1030.

22. Merrill C, Nagamine M, Elixhauser A. Hospital Stays Involv-ing Pulmonary Heart Disease, 2005. HCUP Statistical Brief#43. Rockville, MD: Agency for Health Care Research andQuality; 2007.

23. Minai OA, Nathan SD, Hill NS, Badesch DB, Stoller JK.

Pulmonary hypertension in lung diseases: Survey of beliefsand practice patterns. Respir Med. 2010;104(5):741-748.

24. Rich S. The current treatment of pulmonary arterial hyperten-sion: time to redefine success. Chest. 2006;130(4):1198-1202.

25. Highland KB, Strange C, Mazur J, Simpson KN. Treatmentof pulmonary arterial hypertension: a preliminary decisionanalysis. Chest. 2003;124(6):2087-2092.

26. Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arte-rial hypertension: baseline characteristics from the REVEALRegistry. Chest. 2010;137(2):376-387.

27. Allan GM, Lexchin J, Wiebe N. Physician awareness of drugcost: a systematic review. PLoS Med. 2007;4(9):e283.

28. Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal ofthe use of inferior vena cava for estimating right atrial pres-sure.J Am Soc Echocardiogr. 2007;20(7):857-861.

29. Raymond RJ, Hinderliter AL, Willis PW, et al. Echocardio-graphic predictors of adverse outcomes in primary pulmonaryhypertension.J Am Coll Cardiol. 2002;39(7):1214-1219.

30. Barst RJ, McGoon M, Torbicki A, et al. Diagnosis and dif-ferential assessment of pulmonary arterial hypertension.

J Am Coll Cardiol. 2004;43(12 Suppl S):40S-47S.

http://www.chestpubs.org/http://clinicaltrials.gov/ct2/show/NCT00495638http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://www.chestpubs.org/http://clinicaltrials.gov/ct2/show/NCT00495638


8/8

DOI 10.1378/chest.10-1269; Prepublished online September 23, 2010;2011;139; 988-993Chest

RichJonathan D. Rich, Sanjiv J. Shah, Rajiv S. Swamy, Anna Kamp and Stuart

Implications for Clinical PracticeArtery Pressures in Patients With Pulmonary Hypertension :

Inaccuracy of Doppler Echocardiographic Estimates of Pulmonary

June 15, 2011This information is current as of

http://chestjournal.chestpubs.org/content/suppl/2011/05/03/chest.10-1269.DC1.htmlView e-supplements related to this article at:Supplementary Material

http://chestjournal.chestpubs.org/content/139/5/988.full.htmlUpdated Information and services can be found at:

Updated Information & Services

http://chestjournal.chestpubs.org/content/139/5/988.full.html#ref-list-1This article cites 28 articles, 19 of which can be accessed free at:

References

http://chestjournal.chestpubs.org/content/139/5/988.full.html#related-urlsThis article has been cited by 2 HighWire-hosted articles:

Cited Bys

http://www.chestpubs.org/site/misc/reprints.xhtmlfound online at:Information about reproducing this article in parts (figures, tables) or in its entirety can bePermissions & Licensing

http://www.chestpubs.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

Reprints

"Services" link to the right of the online article.Receive free e-mail alerts when new articles cite this article. To sign up, select the

Citation Alerts

PowerPoint slide format. See any online figure for directions.articles can be downloaded for teaching purposes inCHESTFigures that appear in

Images in PowerPoint format

2011 A i C ll f Ch t Ph i iat Rush Univ Med Lib on June 15, 2011chestjournal.chestpubs.orgDownloaded from
http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/content/139/5/988.full.htmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.htmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.htmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.html#ref-list-1http://chestjournal.chestpubs.org/content/139/5/988.full.html#ref-list-1http://chestjournal.chestpubs.org/content/139/5/988.full.html#ref-list-1http://chestjournal.chestpubs.org/content/139/5/988.full.html#related-urlshttp://chestjournal.chestpubs.org/content/139/5/988.full.html#related-urlshttp://chestjournal.chestpubs.org/content/139/5/988.full.html#related-urlshttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/content/139/5/988.full.html#related-urlshttp://chestjournal.chestpubs.org/content/139/5/988.full.html#ref-list-1http://chestjournal.chestpubs.org/content/139/5/988.full.html