Copyright © 2006, The European Society of Cardiology
Pulmonary hypertension and exercise echocardiography
Unit of Autoimmune Diseases, Hospital Clínico San Cecilio, Granada, Spain
Received 9 February 2006; accepted after revision 19 March 2006.
* Corresponding author. Tel.: +34 958023464. jlcalleja{at}telefonica.net
Keywords: Pulmonary hypertension; Exercise echocardiography; Scleroderma
We have read with interest the article of Collins et al. on pulmonary hypertension assessment and screening evaluation using stress echocardiography.1 The authors made an attempt to determine the prevalence of pulmonary arterial hypertension (PAH) at exercise in patients registered with autoimmune disease (systemic lupus erythematosus, limited systemic sclerosis and diffuse systemic sclerosis).
They refer that in normal individuals the pulmonary arterial pressure (PAP) remains essentially unchanged and defined pulmonary hypertension (PAH) as systolic pulmonary artery (SPAP)>35mmHg with right atrial pressure of 10mmHg. They reported a prevalence of 59% using this cut-off; no correlation between DLCO and PAH was found. The question is: are really these patients a risk population of PAH?
Bossone et al.2 evaluated athletes and nonathletes with Doppler echocardiography at rest and during bicycle exercise and demonstrated mild increases in pulmonary pressure with exercise. Grünig et al.3 performed a stress Doppler echocardiography during supine bicycle exercise on families with PPH; they estimated right atrial pressure in 5mmHg (instead of 10mmHg) and considered abnormal response when PASP was >40mmHg. In all participants the mean PASP was increased at exercise.
While diagnosis of HPA by heart catheterisation still remains the gold standard, Doppler echocardiography is the most practical and reliable non-invasive tool to survey for disease. The reported prevalence of PAH in scleroderma has showed wide variation depending on the methodology, population and definition of PAH used.4–6 An SPAP at rest between 40 and 45mmHg has a positive predictive value (92 and 98%). The cut-off of SPAP at exercise has not been established. We think that, like for the definition of pulmonary hypertension, the value at exercise must be higher than at rest (probably a cut-off of 50–55mmHg).
Therefore the cut-off used in this study is, in our opinion, inadequate and the prevalence of "subclinic" PAH is excessively high.
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- Collins N., Bastian B., Jones C., Morgan R., Reeves G. Abnormal pulmonary vascular responses in patients registered with a systemic autoimmunity database: pulmonary hypertension assessment and screening evaluation using stress echocardiography (PHASE-I). Eur J Echocardiogr (2006) 19:1–8.
- Bossone E., Rubenfire M., Bach D.S., Ricciardi M., Armstrong W.F. Range of tricuspid regurgitation velocity at rest and during exercise in normal adult men: implications for the diagnosis of pulmonary hypertension. Arthritis Rheum (2005) 52:2125–2132.[CrossRef][Web of Science][Medline]
- Grünig E., Janssen B., Mereles D., Barth U., Borst M.M., Vogt R.I., et al. Abnormal pulmonary artery pressure response in asymptomatic carriers of primary pulmonary hypertension gene. Circulation (2000) 102:1145–1150.
[Abstract/Free Full Text] - Pope J.E., Baron M., Dunne J., Smith D., Docherty P.S., Bookman A., et al. Prevalence of elevated pulmonary arterial pressures measured by echocardiography in a multicenter study of patients with systemic sclerosis. J Rheumatol (2005) 32:1273–1278.
[Abstract/Free Full Text] - Mukerjee D., George D.S., Coleiro B., Knight C., Denton C.P., Davar J., et al. Prevalence and outcome in systemic sclerosis associated pulmonary arterial hypertension: application of a registry approach. Ann Rheum Dis (2003) 62:1088–1093.
[Abstract/Free Full Text] - Wigley F.M., Lima J.A., Mayes M., McLain D., Lincoln Chapin J., Ward-Able C. The prevalence of undiagnosed pulmonary arterial hypertension in subjects with connective tissue disease at the secondary health care level of community-based rheumatologist (the UNCOVER study). Arthritis Rheum (2005) 52:2125–2132.[CrossRef][Web of Science][Medline]
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