Is a right ventricular systolic pressure (RVSP) of 35 mmHg concerning?

From the Guidelines

An RVSP of 35 mmHg is considered mildly elevated and may be concerning, particularly in the context of liver transplantation, where a mean pulmonary arterial pressure >35 mmHg is associated with increased mortality 1.

Clinical Context

In patients with compensated liver disease, portopulmonary hypertension alone is not an indication for liver transplantation (LT) 1. However, vasomodulator therapy should be offered to all LT candidates with porto-pulmonary hypertension and mean pulmonary arterial pressure >35 mmHg and pulmonary vascular resistance >3 Wood units 1.

Recommendations

I recommend discussing this finding with your healthcare provider to determine if additional testing is needed, such as a more comprehensive echocardiogram, pulmonary function tests, or a sleep study 1. Some key points to consider:

• Normal RVSP typically ranges from 15-25 mmHg, so a value of 35 mmHg suggests mild pulmonary hypertension.
• The elevation in pressure indicates increased resistance in the pulmonary circulation, which forces the right ventricle to work harder to pump blood through the lungs.
• Common causes include left heart disease, lung conditions like COPD, sleep apnea, blood clots in the lungs, or connective tissue disorders.
• Identifying and addressing the underlying cause is important to prevent progression to more severe pulmonary hypertension.

Further Evaluation

Further evaluation is necessary to determine the underlying cause of the elevated RVSP and to assess the severity of pulmonary hypertension. This may include:

• A comprehensive echocardiogram to assess right ventricular function and estimate pulmonary artery pressure.
• Pulmonary function tests to assess lung function and detect any underlying lung disease.
• A sleep study to diagnose sleep apnea, which can contribute to pulmonary hypertension.
• Laboratory tests, such as a complete blood count and comprehensive metabolic panel, to rule out other underlying conditions.

From the Research

Right Ventricular Systolic Pressure (RVSP) Concerns

• RVSP is a measure used to assess the presence and severity of pulmonary hypertension, which is a common condition among patients with heart failure (HF) 2.
• A RVSP of 35 mm Hg is considered mildly elevated, and according to a study published in 2023, patients with mildly elevated RVSP have a higher risk of hospitalization and mortality due to heart failure 2.
• The study categorized RVSP into four groups: normal (< 40 mm Hg), mildly elevated (40-49 mm Hg), moderately elevated (50-59 mm Hg), and severely elevated (≥ 60 mm Hg) 2.
• Patients with mildly elevated RVSP had a hazard ratio (HR) of 1.31 for heart failure hospitalization or all-cause mortality, indicating a significant increase in risk compared to those with normal RVSP 2.

Diagnostic and Prognostic Role of Echocardiography

• Echocardiography is a useful tool for screening, differential diagnosis, follow-up assessments, and risk stratification in pulmonary hypertension 3.
• The technique provides accurate measurements of pulmonary hemodynamics, either at rest or during exercise, and is particularly useful in ruling out secondary causes of pulmonary hypertension and detecting preclinical stages 3.
• Advanced noninvasive imaging techniques may provide additional information in assessing right heart structure and function 3.

Estimation of RVSP using Echo-Doppler

• A new formula for echo-Doppler estimation of RVSP was proposed in 1994, which takes into account the estimation of right atrial pressure by means of the inferior vena cava collapsibility index (IVCCI) 4.
• The formula was compared with traditional formulas and cardiac catheterization values, and it was found to improve noninvasive estimation of RVSP in certain patient groups 4.

Clinical Implications

• Patients with RVSP of 35 mm Hg should be closely monitored and may require more aggressive medical therapy to slow disease progression and improve quality of life 2, 5.
• The use of targeted therapies, such as phosphodiesterase type-5 inhibitors, endothelin receptor antagonists, and prostacyclin analogues, may be beneficial in patients with pulmonary arterial hypertension associated with systemic sclerosis 5.