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Accuracy of Doppler Echocardiography in the Hemodynamic Assessment of Pulmonary Hypertension

Micah R. Fisher^1,*, Paul R. Forfia^2,, Elzbieta Chamera², Traci Housten-Harris¹, Hunter C. Champion², Reda E. Girgis¹, Mary C. Corretti² and Paul M. Hassoun¹

¹ Division of Pulmonary and Critical Care Medicine; ² Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland

Correspondence and requests for reprints should be addressed to Paul M. Hassoun, M.D., Division of Pulmonary and Critical Care Medicine, 5501 Hopkins Bayview Circle, Baltimore, MD 21224. E-mail: phassoun{at}jhmi.edu

Rationale: Transthoracic Doppler echocardiography is recommended for screening for the presence of pulmonary hypertension (PH). However, some recent studies have suggested that Doppler echocardiographic pulmonary artery pressure estimates may frequently be inaccurate.

Objectives: Evaluate the accuracy of Doppler echocardiography for estimating pulmonary artery pressure and cardiac output.

Methods: We conducted a prospective study on patients with various forms of PH who underwent comprehensive Doppler echocardiography within 1 hour of a clinically indicated right-heart catheterization to compare noninvasive hemodynamic estimates with invasively measured values.

Measurements and Main Results: A total of 65 patients completed the study protocol. Using Bland-Altman analytic methods, the bias for the echocardiographic estimates of the pulmonary artery systolic pressure was –0.6 mm Hg with 95% limits of agreement ranging from +38.8 to –40.0 mm Hg. Doppler echocardiography was inaccurate (defined as being greater than ±10 mm Hg of the invasive measurement) in 48% of cases. Overestimation and underestimation of pulmonary artery systolic pressure by Doppler echocardiography occurred with a similar frequency (16 vs. 15 instances, respectively). The magnitude of pressure underestimation was greater than overestimation (–30 ± 16 vs. +19 ± 11 mm Hg; P = 0.03); underestimates by Doppler also led more often to misclassification of the severity of the PH. For cardiac output measurement, the bias was –0.1 L/min with 95% limits of agreement ranging from +2.2 to –2.4 L/min.

Conclusions: Doppler echocardiography may frequently be inaccurate in estimating pulmonary artery pressure and cardiac output in patients being evaluated for PH.

Key Words: echocardiography • pulmonary hypertension • pulmonary systolic pressure • cardiac output • accuracy

Scientific Knowledge on the Subject Although Doppler echocardiography (DE) is recommended as a screening tool for the diagnosis of pulmonary hypertension (PH), its accuracy in estimating pulmonary artery systolic pressure in PH patients has been questioned. The value of DE for estimating cardiac output (CO) in these patients has not been assessed. What This Study Adds to the Field This prospective study demonstrates that DE can frequently overestimate and underestimate pulmonary artery pressure in PH patients. This error is in part explained by inaccuracies of right atrial pressure estimation and poor Doppler imaging of the transtricuspid regurgitant jet. The estimation of CO by DE does not appear to be reliable.

 

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