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Lung diseases

Pulmonary Hypertension

06/16/2010

Question:

i had an echo for tricuspid murmur which showed estimated RVSP of 51 and estimated RAP of 12... the cardiologist has scheduled me for right heart cath even though i am asymptomatic and cycle 50 miles on my road bike with no SOB or chest pain or other symptoms and says i have `moderate PH`... i am 40 year old fit and active athletic female... any input into whether RHC are indicated is welcome please...

Answer:

The answer to this involves understanding the potential accuracy (or lack thereof) of an echocardiogram estimation of true pulmonary arterial pressures. In general, echocardiography is an excellent screening tool for pulmonary hypertension in that it rarely "misses" cases of pulmonary arterial hypertension (PAH). The problem is that echos are not as specific as one might hope. In other words, echos say that many people (up to one half of some populations screened) may have elevated pressures - when in fact they do not. One of the most common signs of true PAH at more advanced stages is exercise limitation, which does not seem to be the case in this person. What was not contained within the question was the purpose of the original echo - were there other symptoms that prompted the study. Taken together, one possible explanation of the limited data supplied by the question submitter is that the echo is wrong and that there is no pulmonary hypertension on the other hand, the decision to pursue confirmatory cath rarely rests only on one piece of information such as the RVSP.

I cannot directly answer the question about whether this patient with all additional data taken together requires a right heart cath. National treatment guidelines recommend that:
1) patients in whom the diagnosis of PAH is being considered should be evaluated by a center specializing in the care and diagnosis of PAH.
2) Any patient in whom the diagnosis needs to be confirmed receive a right heart catheterization.

I would recommend that these concerns be forwarded to and discussed with their physician. If there still are concerns, seeking additional input from a specialist in the area is reasonable especially when serious conditions or invasive procedures are being considered. There are several large centers in all parts of the country that have sections that specialize in research, diagnosis and treatment of pulmonary hypertension. An evaluation at one of these centers may be of benefit.

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Response by:

Robert  Schilz, DO, PhD Robert Schilz, DO, PhD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University