TY - JOUR T1 - Noninvasive Evaluation of Pulmonary Artery Pressure during Exercise: The Importance of Right Atrial Hypertension JF - European Respiratory Journal JO - Eur Respir J DO - 10.1183/13993003.01617-2019 SP - 1901617 AU - Masaru Obokata AU - Garvan C. Kane AU - Hidemi Sorimachi AU - Yogesh N. V. Reddy AU - Thomas P. Olson AU - Alexander C. Egbe AU - Vojtech Melenovsky AU - Barry A. Borlaug Y1 - 2019/01/01 UR - http://erj.ersjournals.com/content/early/2019/11/07/13993003.01617-2019.abstract N2 - Introduction Identification of elevated pulmonary artery (PA) pressures during exercise has important diagnostic, prognostic, and therapeutic implications. Stress echocardiography is frequently used to estimate PA pressures during exercise testing, but data supporting this practice are limited. This study examined the accuracy of Doppler echocardiography for the estimation of PA pressures at rest and during exercise.Methods Simultaneous cardiac catheterisation-echocardiographic studies were performed at rest and during exercise in 97 subjects with dyspnea. Echocardiography-estimated PA systolic pressure (ePASP) was calculated from the right ventricular to right atrial pressure gradient (eRV-RA) and estimated RA pressure (eRAP), and then compared with directly measured PASP and RAP.Results Estimated PASP was obtainable in 57% of subjects at rest, but feasibility decreased to 15–16% during exercise, due mainly to an inability to obtain eRAP during stress. Estimated PASP correlated well with direct PASP at rest (r=0.76, p<0.0001; bias −1 mmHg) and during exercise (r=0.76, p=0.001; bias +3 mmHg). When assuming eRAP of 10 mmHg, ePASP10 correlated with direct PASP (r=0.70, p<0.0001), but substantially underestimated true values (bias +9 mmHg), with the greatest underestimation among patients with severe exercise-induced pulmonary hypertension (EIPH). Estimation of eRAP during exercise from resting eRAP improved discrimination of patients with or without EIPH (AUC=0.81), with minimal bias (5 mmHg), but wide limits of agreement (−14 mmHg to 25 mmHg).Conclusions The RV-RA pressure gradient can be estimated with reasonable accuracy during exercise when measurable. However, RA hypertension frequently develops in patients with EIPH, and the inability to noninvasively account for this leads to substantial underestimation of exercise PA pressures.FootnotesThis manuscript has recently been accepted for publication in the European Respiratory Journal. It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article.Conflict of interest: Dr. Obokata has nothing to disclose.Conflict of interest: Dr. Kane has nothing to disclose.Conflict of interest: Dr. Sorimachi has nothing to disclose.Conflict of interest: Dr. Reddy reports grants from NIH, outside the submitted work.Conflict of interest: Dr. Olson has nothing to disclose.Conflict of interest: Dr. Egbe has nothing to disclose.Conflict of interest: Dr. Melenovsky reports grants from the Czech Healthcare Research Grant agency, outside the submitted work.Conflict of interest: Dr. Borlaug reports grants from NIH, grants from NIH, grants from NIH, grants from NIH, outside the submitted work. ER -