What are the next steps for a patient with a normal right ventricular systolic pressure (RVSP) of 37mmHg on transthoracic echocardiogram (TTE), considering their past medical history and potential symptoms of cardiovascular or pulmonary disease?

Management of RVSP 37 mmHg on Transthoracic Echocardiogram

An RVSP of 37 mmHg falls within the upper range of normal to borderline elevated and does not require immediate intervention or extensive workup in an asymptomatic patient without other concerning findings. 1, 2

Understanding the RVSP Value

• Normal RVSP is typically 21±4 mmHg with an upper limit of approximately 30 mmHg, making 37 mmHg mildly elevated but not definitively abnormal 1
• RVSP >40 mmHg warrants further evaluation in patients with unexplained dyspnea, while severe elevation (≥60 mmHg) indicates high probability of pulmonary hypertension requiring right heart catheterization 2
• Your patient's value of 37 mmHg falls in a gray zone that requires clinical context rather than automatic escalation 2

Immediate Assessment Priorities

Evaluate the complete echocardiographic report for associated findings:

• Right atrial enlargement, right ventricular enlargement, or pericardial effusion suggest hemodynamically significant disease requiring further workup 1
• Right ventricular systolic function (TAPSE ≥17mm is normal) is critical, as RV dysfunction predicts adverse outcomes independent of RVSP 1, 3
• Tricuspid regurgitation severity and mechanism should be assessed, as significant TR can affect RVSP accuracy 4
• Left-sided valve disease or left ventricular dysfunction may explain elevated right-sided pressures 4

Clinical Context Determines Next Steps

For asymptomatic patients with isolated RVSP 37 mmHg and normal RV function:

• No immediate intervention is required 4
• Repeat echocardiography in 2-5 years is reasonable for surveillance, similar to mild pulmonary stenosis protocols 4
• Clinical monitoring is warranted if RVSP >35 mmHg, as this threshold associates with TAPSE decline over time 3

For patients with unexplained dyspnea, exercise intolerance, or other symptoms:

• Exercise testing with Doppler assessment can evaluate the response of pulmonary artery pressure during exertion, as a rise to >60-70 mmHg should prompt careful symptom consideration 4
• Complete the following screening tests to identify underlying etiology: complete blood count, comprehensive metabolic panel, liver function tests, thyroid function, NT-proBNP, HIV serology, ANA, and hepatitis serologies 2
• Pulmonary function tests to assess for underlying lung disease 1
• Ventilation/perfusion scan if chronic thromboembolic disease is suspected (preferred over CT for sensitivity) 2

When to Escalate Workup

Right heart catheterization is NOT indicated at RVSP 37 mmHg unless:

• Severe symptoms are present that are unexplained by other findings 2
• Progressive elevation on serial echocardiograms occurs, particularly if approaching 50 mmHg 5
• Significant RV dysfunction develops (TAPSE <17mm), as this independently predicts heart failure hospitalization 3

Important Caveats

• Echocardiography may underestimate pulmonary artery pressure by a mean of 11 mmHg, with underestimation ≥20 mmHg in up to 31% of patients 2
• However, at RVSP 37 mmHg, even significant underestimation would not indicate severe pulmonary hypertension requiring immediate catheterization 2
• Serial RVSP measurements are more informative than isolated values, as trajectory predicts outcomes in heart failure patients 5
• Risk factors for RV dysfunction progression include heart failure, left-sided valvular disease, and other cardiovascular comorbidities 3

Practical Algorithm

1. Review complete echo for RV size/function, RA enlargement, TR severity, and left-sided abnormalities 1
2. If normal RV function and no symptoms: routine follow-up, repeat echo in 2-5 years 4
3. If symptoms present: exercise testing with Doppler, screening labs, PFTs, consider V/Q scan 4, 1, 2
4. If RV dysfunction or progressive RVSP elevation: refer to pulmonary hypertension specialist for consideration of right heart catheterization 2