Can a coughing episode during catheter-based measurement of left ventricular end‑diastolic pressure (LVEDP) cause a falsely elevated reading?

Yes, a coughing fit during LVEDP measurement can cause falsely elevated readings

Coughing during catheter-based measurement of left ventricular end-diastolic pressure (LVEDP) can produce artifactual pressure elevations and should prompt repeat measurement after the patient settles. This is a well-recognized technical artifact in invasive hemodynamic monitoring.

Mechanism of Artifact

Coughing generates significant intrathoracic pressure changes that are transmitted to cardiac chambers and great vessels. During a cough:

• Intrathoracic pressure spikes dramatically (can exceed 100-200 mmHg during the compressive phase)
• This pressure is transmitted directly to the left ventricle and surrounding structures
• The pressure transducer records the sum of true LVEDP plus the superimposed intrathoracic pressure artifact
• The result is a falsely elevated reading that does not reflect actual left ventricular filling pressure

Recognition and Prevention

The 2025 Chest guidelines on right heart catheterization emphasize the importance of recognizing artifacts during hemodynamic measurements 1. While these guidelines specifically discuss catheter motion artifacts, underdamping, and overdamping, the same principles apply to any physiologic interference:

Key recognition features:

• Sharp, non-physiologic pressure spikes coinciding with cough
• Loss of normal waveform morphology during the episode
• Pressure values that are inconsistent with the clinical picture
• Return to baseline values after coughing resolves

The 2003 ASA guidelines stress that competent interpretation requires "understanding the importance of and ability to recognize artifacts, clinical circumstances under which data may be misleading" 2. This explicitly includes situations where measured pressures do not appropriately reflect true ventricular filling conditions.

Clinical Implications

Proper measurement technique requires:

• Obtaining LVEDP measurements during quiet respiration at end-expiration
• Averaging multiple cardiac cycles (typically 3-5 beats)
• Ensuring the patient is calm and not coughing, straining, or performing Valsalva maneuvers
• Repeating measurements if artifact is suspected
• Correlating measured values with clinical context

Common Pitfalls

1. Accepting a single elevated reading without verification - Always obtain multiple measurements and average them
2. Failing to observe the pressure waveform in real-time - Numerical values alone can be misleading; watch the actual tracing
3. Not documenting the presence of artifacts - Note in the procedure report if measurements were affected by cough or other interference
4. Confusing artifact with true pathology - A sudden spike during cough is not the same as sustained elevation from heart failure or valvular disease

The evidence shows that even under optimal conditions, LVEDP measurements can be discordant with other estimates of filling pressure 3, making it even more critical to obtain high-quality, artifact-free measurements. When elevated LVEDP is detected, ensure it represents true pathophysiology rather than technical artifact by repeating the measurement after the patient has stopped coughing and is breathing quietly.