Abstract
Current guidelines recommend right heart catheterization (RHC) in symptomatic patients at risk of precapillary pulmonary hypertension (PH) with echocardiographic systolic pulmonary pressures (sPAP) ≥36mmHg. Growing awareness for PH, a high prevalence of postcapillary PH and the inability to distinguish between pre- and postcapillary PH by echocardiography have led to unnecessary RHCs. The aim of the present study was to assess whether standard non-invasive diagnostic procedures are able to safely exclude precapillary PH.
Data from 251 patients referred for clinical and echocardiographic suspicion of precapillary PH were used to develop a non-invasive diagnostic decision tree. Bootstrapping was applied for internal validation and a prospectively collected data set of 121 consecutive patients was utilized for temporal validation.
According to the decision tree, patients were stratified by the presence or absence of an electrocardiographic right ventricular strain pattern (RVS) and serum NT-proBNP levels below and above 80pg·mL−1. In the absence of RVS and elevated NT-proBNP, none of the patients in the prospective validation cohort was diagnosed with precapillary PH by RHC. Compared with current indication for RHC that is mainly based on echocardiography, a combination with the diagnostic algorithm increased specificity to 19.3% (p=0.0009), while sensitivity remained 100%.
A diagnostic decision tree employing ECG and NT-proBNP on top of echocardiography helps recognize one false positive case per five patients referred with dyspnoea and echocardiographic suspicion of PH, while not missing true precapillary PH.
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