What does an echocardiogram showing elevated filling pressures and significantly elevated right atrial pressure mean in a 70-year-old female patient with no history of cardiomyopathy, coronary artery disease (CAD), or ischemic disease, and a recently negative stress test?

From the Guidelines

The echocardiogram findings of elevated filling pressures and significantly elevated right atrial pressure in this 70-year-old female patient with no cardiac history suggest right heart dysfunction that requires prompt evaluation. This patient should be referred to a cardiologist for further assessment, as these findings may indicate pulmonary hypertension, right-sided heart failure, or valvular disease such as tricuspid regurgitation. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, the diagnosis of heart failure with preserved ejection fraction (HFpEF) requires evidence of increased LV filling pressures at rest, exercise, or other provocations, which can be fulfilled with findings of elevated levels of natriuretic peptides, echocardiographic diastolic parameters such as an E/e' ≥ 15, or invasive hemodynamic measurement at rest or exercise.

The patient's negative stress test rules out ischemia as a cause, suggesting a primary right heart or pulmonary vascular issue that requires specific diagnosis and targeted treatment. Additional testing should include a complete blood count, comprehensive metabolic panel, BNP or NT-proBNP, and a right heart catheterization to confirm pressures and determine the underlying cause, as recommended by the European Society of Cardiology guidelines 1. A chest CT with pulmonary angiography may be warranted to rule out pulmonary embolism or parenchymal lung disease.

While awaiting specialist evaluation, the patient should be monitored for symptoms of fluid overload, and mild diuretic therapy with furosemide 20-40mg daily may be considered if edema is present. The use of the H2 FPEF score, which integrates predictive variables such as obesity, atrial fibrillation, age > 60 years, treatment with ≥ 2 antihypertensive medications, echocardiographic E/e' ratio > 9, and echocardiographic PA systolic pressure > 35 mm Hg, may help to facilitate discrimination of HFpEF from noncardiac causes of dyspnea and can assist in determination of the need for further diagnostic testing 1.

Key points to consider in the management of this patient include:

• Referral to a cardiologist for further assessment and diagnosis
• Additional testing, including complete blood count, comprehensive metabolic panel, BNP or NT-proBNP, and right heart catheterization
• Monitoring for symptoms of fluid overload and consideration of mild diuretic therapy
• Use of the H2 FPEF score to guide further diagnostic testing and management
• Consideration of pulmonary hypertension, right-sided heart failure, or valvular disease as potential underlying causes of the patient's symptoms and echocardiogram findings.

From the Research

Echocardiogram Results Interpretation

The echocardiogram results for the 70-year-old female patient show elevated filling pressures and significantly elevated right atrial pressure. This indicates that the patient's heart is having trouble filling with blood between beats, which can be a sign of various heart conditions.

Possible Causes and Associations

• Elevated left ventricular filling pressure is associated with heart failure and reduced ejection fraction 2.
• Left ventricular diastolic dysfunction with elevated filling pressures is borderline associated with embolic stroke of undetermined source and significantly associated with atrial fibrillation 3.
• Echocardiographic assessment of left ventricular filling pressures is performed using a multi-parametric algorithm, which can help estimate pulmonary capillary wedge pressure (PCWP) > 15 mmHg in patients with heart failure and reduced ejection fraction 2.

Diagnostic Accuracy and Limitations

• The diagnostic accuracy of echocardiography in estimating high filling pressure in patients with heart failure and reduced ejection fraction can be improved using a multi-parametric algorithm that includes tricuspid regurgitation velocity, left atrial indexed volume, and E wave velocity 2.
• No single echocardiographic parameter is sufficiently reliable to be used clinically to identify elevated left ventricular filling pressure in patients with atrial fibrillation, but a two-step algorithm that combines several echocardiographic parameters and body mass index can classify patients as having normal or elevated left ventricular filling pressure with moderate accuracy and high feasibility 4.

Clinical Implications

• The patient's negative stress test results suggest that coronary artery disease is unlikely to be the cause of the elevated filling pressures and right atrial pressure.
• Further evaluation and monitoring may be necessary to determine the underlying cause of the patient's echocardiogram results and to guide treatment decisions.
• The patient's results highlight the importance of using a multi-parametric approach to echocardiographic assessment of left ventricular filling pressures, as recommended by studies such as 4 and 2.