From the Guidelines
For a patient with a right ventricular systolic pressure (RVSP) of 87 mmHg on echocardiogram, a comprehensive pulmonary hypertension workup is initiated, as outlined in the approach described by Zamanian et al. 1. This workup is necessary because an RVSP of 87 mmHg is significantly elevated, suggesting substantial pulmonary vascular resistance. The initial steps include a thorough review of symptoms, assessment of risk factors for the development of pulmonary hypertension, and screening for any history or evidence of congenital heart disease, autoimmune diseases, liver disease, thromboembolic disease, history of stimulant use, underlying lung disease, heart disease, sleep disordered breathing, and HIV infection, as recommended by Zamanian et al. 1. Key components of the workup include:
- Basic labs: CBC, comprehensive metabolic panel, thyroid function tests, and N-terminal pro B-type natriuretic peptide (NT-proBNP) 1
- Screening electrocardiogram and chest X-ray to alert the clinician to co-existing cardiopulmonary diseases 1
- Pulmonary function tests, six-minute walk test, and non-contrast CT scan of the chest or CT angiogram if thromboembolic disease is suspected 1
- V/Q scan, especially if thromboembolic disease is a likely diagnosis, as either a CT angiogram or V/Q scan can be used as an initial screen but a V/Q scan is required if thromboembolism is still suspected after initial screening 1
- Evaluation for possible sleep apnea and consideration of serologic testing for connective tissue diseases, HIV testing, and liver ultrasound with portal pressure assessment, depending on the patient's risk factors and clinical presentation 1 The comprehensive workup aims to identify the underlying cause of pulmonary hypertension, determine its severity, and guide appropriate management based on the specific etiology (WHO Group 1-5), as treatment approaches differ significantly based on the underlying cause 1.
From the Research
Workup for RVSP 87 on Echo
- The patient's RVSP of 87 on echo suggests potential pulmonary hypertension (PH) 2, 3, 4, 5.
- According to a study published in 2014, an RVSP of 87 would likely correlate with an invasively measured mean pulmonary artery pressure (mPAP) 2.
- However, the correlation between RVSP and mPAP can be imperfect, and right heart catheterization remains the gold standard for diagnosing PH 2, 6, 3, 4, 5.
- A study from 1994 proposed a new formula for estimating RVSP using echo-Doppler, which may improve the accuracy of non-invasive measurements 6.
- Another study from 2010 suggested that an RVSP cutoff of 45 mmHg could be used to exclude severe PH in heart transplant candidates 3.
- However, a study from 2008 found that RVSP was not an accurate test for assessing PH in patients with idiopathic pulmonary fibrosis 4.
- A more recent study from 2017 found that combining RVSP with other echocardiographic parameters, such as right atrial enlargement and pulmonary artery enlargement, could improve the diagnostic characteristics of echo for PH 5.
- The workup for a patient with an RVSP of 87 on echo may include: + Right heart catheterization to confirm the diagnosis of PH and measure mPAP 2, 3, 4, 5 + Additional echocardiographic parameters, such as right atrial enlargement and pulmonary artery enlargement, to improve the diagnostic accuracy of echo 5 + Clinical evaluation and other diagnostic tests, such as pulmonary function tests and 6-minute walk test, to assess the patient's overall condition and risk stratify for PH 4