From the Guidelines
The next step in evaluation after an echocardiogram for an obese patient with right axis deviation, right ventricular dilation, normal jugular venous pressure (JVP), and cardiomegaly on chest X-ray would be a comprehensive pulmonary hypertension workup, including a screening for underlying conditions such as sleep disordered breathing, as outlined in the Stanford Approach 1.
This approach is based on the current clinical management of pulmonary arterial hypertension, which emphasizes the importance of accurate diagnosis and full characterization of the disease phenotype 1. The patient's echocardiogram showing right ventricular dilation and right axis deviation, combined with the presence of cardiomegaly on chest X-ray, suggests the possibility of pulmonary hypertension.
Given the patient's obesity, a sleep study to evaluate for obstructive sleep apnea (OSA) is a crucial part of the workup, as OSA is highly prevalent in obese individuals and can lead to pulmonary hypertension 1. The normal JVP suggests that the right heart failure may not be advanced, but the right ventricular changes indicate ongoing pressure overload.
The comprehensive workup should also include:
- Routine studies such as a CBC, comprehensive metabolic panel, thyroid function, and N-terminal pro B-type natriuretic peptide (NT-proBNP) 1
- Screening for underlying conditions such as congenital heart disease, autoimmune diseases, liver disease, thromboembolic disease, and HIV infection 1
- Pulmonary function tests to rule out other causes of pulmonary hypertension such as chronic obstructive pulmonary disease 1
- A six-minute walk test to assess the patient's functional capacity 1
- A non-contrast CT scan of the chest or CT angiogram if thromboembolic disease is suspected, and a V/Q scan to evaluate for pulmonary embolism 1
If the initial workup suggests pulmonary hypertension, right heart catheterization may be necessary to directly measure pulmonary pressures and guide specific therapy for pulmonary hypertension 1.
From the Research
Next Steps in Evaluation
After an ECHO has been performed on an obese individual with right axis deviation, right ventricular dilation, normal JVP, and cardiomegaly on CXR, the next steps in evaluation should focus on further assessing pulmonary artery pressure and right heart function.
- The patient's symptoms and echocardiographic findings suggest the possibility of pulmonary hypertension (PH), which requires a comprehensive evaluation to determine the underlying cause and severity of the disease 2, 3, 4.
- Echocardiography plays a crucial role in the diagnostic algorithm of PH, providing an estimate of right ventricular function and pulmonary artery pressure, as well as helping to rule out secondary causes of PH such as left heart disease or congenital heart disease 4, 5.
- Given the patient's right ventricular dilation, it is essential to assess the clinical and prognostic significance of this finding, as a larger RV diameter has been associated with a poor prognosis in patients with idiopathic pulmonary arterial hypertension 6.
- Further evaluation may involve additional imaging modalities, such as cardiac catheterization, to confirm the diagnosis and assess the severity of PH, as well as to guide treatment decisions 2, 3, 5.
- A multimodality approach, including echocardiography, may be necessary to accurately assess right heart function and guide treatment options 4, 5.