title: Accuracy of Echocardiography to Estimate Pulmonary Artery Pressures With Exercise: A Simultaneous Invasive-Noninvasive Comparison.
abstract: BACKGROUND
  Exercise echocardiography is often applied as a noninvasive strategy to screen for abnormal pulmonary hemodynamic response, but it is technically challenging, and limited data exist regarding its accuracy to estimate pulmonary arterial pressure during exercise.
  
  
  RESULTS
  Among 65 patients with exertional intolerance undergoing upright invasive exercise testing, tricuspid regurgitation (TR) Doppler estimates and invasive measurement of pulmonary arterial pressure at rest and peak exercise were simultaneously obtained. TR Doppler envelopes were assessed for quality. Correlation, Bland-Altman, and receiver-operating characteristic curve analyses were performed to evaluate agreement and diagnostic accuracy. Mean age was 62±13 years, and 31% were male. High-quality (grade A) TR Doppler was present in 68% at rest and 34% at peak exercise. For grade A TR signals, echocardiographic measures of systolic pulmonary arterial pressure correlated reasonably well with invasive measurement at rest (r=0.72,P<0.001; bias, -2.9±8.0 mm Hg) and peak exercise (r=0.75,P<0.001; bias, -1.9±15.6 mm Hg). Lower quality TR signals (grade B and C) correlated poorly with invasive measurements overall. In patients with grade A TR signals, mean pulmonary arterial pressure-to-workload ratio at a threshold of 1.4 mm Hg/10 W was able to identify abnormal pulmonary hemodynamic response during exercise (>3.0 mm Hg/L per minute increase), with 91% sensitivity and 82% specificity (area under the curve, 0.90; 95% confidence interval, 0.77-1.0;P=0.001).
  
  
  CONCLUSIONS
  Agreement between echocardiographic and invasive measures of pulmonary pressures during upright exercise is good among the subset of patients with high-quality TR Doppler signal. While the limits of agreement are broad, our results suggest that in those patients, sensitivity is adequate to screen for abnormal pulmonary hemodynamic response during exercise.
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Annelieke C M J
authors.initials: AC
authors.lastname: van Riel
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Alexander R
authors.initials: AR
authors.lastname: Opotowsky
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Mário
authors.initials: M
authors.lastname: Santos
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Jose M
authors.initials: JM
authors.lastname: Rivero
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Andy
authors.initials: A
authors.lastname: Dhimitri
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Barbara J M
authors.initials: BJ
authors.lastname: Mulder
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Berto J
authors.initials: BJ
authors.lastname: Bouma
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Landzberg
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: Aaron B
authors.initials: AB
authors.lastname: Waxman
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
authors.forename: David M
authors.initials: DM
authors.lastname: Systrom
authors.affiliation: From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.). ashah11@partners.org.
authors.forename: Amil M
authors.initials: AM
authors.lastname: Shah
mesh_terms: D000368:Aged; D019540:Area Under Curve; D062186:Arterial Pressure; D002407:Catheterization, Swan-Ganz; D015150:Echocardiography, Doppler; D025401:Echocardiography, Stress / Q000379:methods*; D005080:Exercise Test; D017079:Exercise Tolerance; D005260:Female; D006801:Humans; D006976:Hypertension, Pulmonary / Q000000981:diagnostic imaging* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning; D011237:Predictive Value of Tests; D011651:Pulmonary Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology; D012372:ROC Curve; D015203:Reproducibility of Results; D012189:Retrospective Studies; D014261:Tricuspid Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D014262:Tricuspid Valve Insufficiency / Q000000981:diagnostic imaging / Q000503:physiopathology
keywords: arterial pressure; catheterization; exercise echocardiography; exercise testing; pulmonary hypertension