Chest
Volume 138, Issue 2, August 2010, Pages 270-278
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Original Research
Echocardiography
Assessment of Pulmonary Arterial Pressure During Exercise in Collagen Vascular Disease: Echocardiography vs Right-Sided Heart Catheterization

https://doi.org/10.1378/chest.09-2099Get rights and content

Background

This study compared the results of exercise Doppler echocardiography (EDE) with right-sided heart catheterization (RHC) and evaluated the combination of EDE and cardiopulmonary exercise testing (CPET) as a screening method for early pulmonary vasculopathy in patients with connective tissue disease.

Methods

Patients (N = 52) with connective tissue disease (predominantly systemic sclerosis) and without known pulmonary arterial hypertension underwent both EDE and CPET. If systolic pulmonary arterial pressure (SPAP) was >40 mm Hg during exercise or peak oxygen uptake (

o2) was <75% predicted, RHC was suggested.

Results

EDE showed an SPAP > 40 mm Hg during exercise in 26/52 patients. Additionally, CPET showed a peak

o2 <75% predicted in 10/26 patients with SPAP ≤ 40 mm Hg upon exercise. Accordingly, RHC was suggested to 36 patients. RHC was performed in 28 of these patients, revealing SPAP > 40 mm Hg in 25 patients (n = 1 at rest, n = 24 during exercise). SPAP values assessed by EDE showed no significant difference vs RHC at rest, 25 W, 50 W, and maximal exercise (difference [95% CI]: 0.3 [−2.7; 3.2], −1.3 [−7.1; 4.4], 0.9 [−7.7; 5.9], and −5.6 [−13.5; 2.2] mm Hg). Eight patients with exercise SPAP > 40 mm Hg had an exercise pulmonary arterial wedge pressure > 20 mm Hg, suggesting exercise-induced left ventricular diastolic dysfunction not detectable by EDE.

Conclusions

EDE appears to be a reasonable noninvasive method to detect SPAP increase during exercise in connective tissue disease. In combination with CPET, it may be a useful screening tool for early pulmonary vasculopathy, although RHC remains the gold standard for hemodynamic assessment.

Trial registration

clinicaltrials.gov; Identifier: NCT00609349 (Early Recognition of Pulmonary Arterial Hypertension)

Section snippets

Materials and Methods

Patients with connective tissue disease were referred to our center for inclusion in this study. They were all diagnosed by an expert panel, including rheumatologists, dermatologists, angiologists, cardiologists, and pulmonologists, according to American College of Rheumatology criteria.27, 28, 29 Exclusion criteria were a history of PAH or a known SPAP > 40 mm Hg at rest based on previous echocardiography, severe lung or bronchial disease (FEV1 <65% predicted), systolic or diastolic left

Results

Ninety-one patients with connective tissue disease were screened for inclusion and exclusion criteria, and 55 patients were ultimately enrolled in the study. The other 36 patients were not enrolled because of significant lung (n = 7) or cardiac (n = 8) disease, preexisting pulmonary hypertension (n = 9), or refusal to participate (n = 12). Three further patients with systemic sclerosis (two with limited and one with diffuse cutaneous systemic sclerosis) were excluded after EDE because of

Discussion

We examined patients with a well-defined, long-standing diagnosis of connective tissue disease without relevant pulmonary fibrosis or known PAH. We applied a combination of CPET with EDE to screen for PAH. A considerable number of these patients underwent RHC at rest and exercise. In accordance with previous studies performing hemodynamic measurements during exercise,32, 33, 34, 35, 36 pressure values were averaged over several respiratory cycles. Also, during stress echocardiography no breath

Conclusions

EDE appears to be a useful, noninvasive method to assess SPAP at rest and during graded exercise in connective tissue disease. The combination of EDE with CPET increases the sensitivity to detect exercise SPAP > 40 mm Hg, but RHC remains the gold standard for assessment of PAH.

Acknowledgments

Author contributions: Dr. Kovacs: initiated and performed the study and interpreted the results.

Dr Maier: performed the Doppler echocardiography examinations in all patients.

Dr Aberer: provided patients for the study after careful examination and worked on the manuscript.

Dr Brodmann: provided patients for the study after careful examination and worked on the manuscript.

Dr Scheidl: provided patients for the study after careful examination and worked on the manuscript.

Dr Hesse: provided patients

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  • Cited by (0)

    Funding/support: This study was sponsored by an unrestricted grant from Actelion Austria and Aktion Österreich-Ungarn, an international nonprofit organization.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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