How Will the New ERS/ESC PH Echocardiography Guidelines Apply to Your Practice?

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Dr. McLaughlin:
Hello, I'm Vallerie McLaughlin, a Cardiologist at the University of Michigan. And welcome to this segment on how will the ERS/ESC PH echocardiography guidelines apply to our practice.

While we were really excited this year to have new evidence-based guidelines for the diagnosis and management of pulmonary hypertension. And there are lots of things that the ERS/ESC guidelines did that were really, really nice. There are some beautiful images that I'm going to highlight. But let's talk about the diagnosis itself. There's a diagnostic algorithm in these new guidelines that really focuses on patients with unexplained dyspnea. And it's really geared towards the primary care provider who is evaluating a patient with unexplained dyspnea. And of course, they're going to start with an H&P, and EKG, and BNP, that sort of thing. And then this kind of bifurcates into, is it more likely a heart problem or more likely a lung problem. And of course, echocardiography is one of the first heart tests that we order in patients who are dyspneic. And in reality, it's one of the first tests that pulmonologists order, too. So I think it's important to emphasize the cross-talk between those two areas.

So echo, it's usually what gets patients in our door. And probably one of the most common questions I get asked when I lecture is, ‘Okay, so what RVSP should I be worried about? And I always say it's so much more than RVSP. And I think that's one of the beautiful things about these new guidelines. They really highlight all of the echocardiography parameters that are important in determining the likelihood of pulmonary hypertension.

And this is figure four from the guidelines that really goes into great detail what we learn from the rest of echo, not just the RVSP. But what we learn from the 2D echo about right ventricular size and function, what we learn from other Doppler measurements, indices of RV functions such as TAPSE and fractional area change. I'm not going to go into this in detail, because you're getting much more specifics on this from other lectures in this particular series. But the important point here is that there are many signs to look for on echo that give us an idea about the presence of pulmonary hypertension, other than just the tricuspid regurgitant velocity.

And I've said on numerous occasions, I want to take this figure and laminate it and hang it in every single echo lab in the country, because I think it really hits home, the important images that need to be obtained. And in reality, sometimes we don't do as good of a job obtaining some of these images and measurements because many echocardiographers and echo technicians and echo labs really spend most of their time focusing on the left side of the heart. So I think it's really important to emphasize what we learn from the right side of the heart.

Then, of course, the next figure in the guidelines really tells us how to integrate that. So it looks at not just the estimated RVSP, which is displayed on this figure as the tricuspid regurgitant velocity, but also the presence of other echo signs, like the ones that I just showed you. And it gives you a little flow diagram. So I think it's important to remember that if someone doesn't have a high TR velocity, but there are other echo signs of pulmonary hypertension, we still might be worried about that patient, that might still be an intermediate probability patient, that we say, gosh, we need to further evaluate them. Or if they have a high estimated RVSP, but they don't have any other signs, you might wonder, you know, is that a reliable measurement? So I think it's really important to look at both the TR velocity and the other echo signs.

And then it takes it one step further. It says do they have risk factors? Because someone, for example, with scleroderma who has a risk factor, maybe their echo is just mildly abnormal, but that risk factor makes you a little bit more worried. So you have to integrate that as well. When you make a decision, do I - how do I follow this patient up? So maybe it is not really clear. Maybe the echo was very subtle, and they don't have any other signs that are risk factors such as risk factors for CTEPH or scleroderma. And you say, okay, I'm just going to follow this patient with an echo, as opposed to being more aggressive and doing a right heart catheterization.

And I think this kind of is a beautiful image to say, we have to look at not just TR velocity, but the other echo signs, and then put that into the context of the patient's history to make the best decision we can for the patient. So I think the guidelines really helped clarify that in a very beautiful way with some of these images.

So I hope you enjoy this series and learn a lot about echocardiography in pulmonary hypertension. Thank you for joining us today.

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