Skip to main content
Download PDF

Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography

Echo Research & Practice volume 5, pages G11–G24 (2018)Cite this article

An Erratum to this article was published on 01 September 2019

This article has been updated

Abstract

Pulmonary hypertension is defined as a mean arterial pressure of ≥25 mmHg as confirmed on right heart catheterisation. Traditionally, the pulmonary arterial systolic pressure has been estimated on echo by utilising the simplified Bernoulli equation from the peak tricuspid regurgitant velocity and adding this to an estimate of right atrial pressure. Previous studies have demonstrated a correlation between this estimate of pulmonary arterial systolic pressure and that obtained from invasive measurement across a cohort of patients. However, for an individual patient significant overestimation and underestimation can occur and the levels of agreement between the two is poor. Recent guidance has suggested that echocardiographic assessment of pulmonary hypertension should be limited to determining the probability of pulmonary hypertension being present rather than estimating the pulmonary artery pressure. In those patients in whom the presence of pulmonary hypertension requires confirmation, this should be done with right heart catheterisation when indicated. This guideline protocol from the British Society of Echocardiography aims to outline a practical approach to assessing the probability of pulmonary hypertension using echocardiography and should be used in conjunction with the previously published minimum dataset for a standard transthoracic echocardiogram.

Change history

References

  1. Wharton G, Steeds R, Allen J, Phillips H, Jones R, Kanagala P, Lloyd G, Masani N, Mathew T, Oxborough D, et al. A minimum dataset for a standard adult transthoracic echocardiogram: a guideline protocol from the British Society of Echocardiography. Echo Research and Practice 20152 G9–G24. (https://doi.org/10.1530/ERP-14-0079)

    Article  Google Scholar 

  2. Galie N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European Heart Journal 201637 67–119. (https://doi.org/10.1093/eurheartj/ehv317)

    Article  Google Scholar 

  3. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Lung B, Lancellotti P, Lansac E, Munoz DR, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal 201738 2739–2791. (https://doi.org/10.1093/eurheartj/ehx391)

    Article  Google Scholar 

  4. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 201770 252–289. (https://doi.org/10.1016/j.jacc.2017.03.011)

    Google Scholar 

  5. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease. Circulation 2014129 e650. (https://doi.org/10.1161/CIR.0000000000000029)

    Google Scholar 

  6. Gillam LD, Marcoff L. Hemodynamics in primary mitral regurgitation. Circulation: Cardiovascular Imaging 201811 e007471. (https://doi.org/10.1161/CIRCIMAGING.118.007471)

    Google Scholar 

  7. Hoeper MM, Kramer T, Pan Z, Eichstaedt CA, Spiesshoefer J, Benjamin N, Olsson KM, Meyer K, Vizza CD, Vonk-Noordegraaf A, et al. Mortality in pulmonary arterial hypertension: prediction by the 2015 European pulmonary hypertension guidelines risk stratification model. European Respiratory Journal 201750 1700740. (https://doi.org/10.1183/13993003.00740-2017)

    Article  Google Scholar 

  8. Oudiz RJ. Death in pulmonary arterial hypertension. American Journal of Respiratory and Critical Care Medicine 2013188 269–270. (https://doi.org/10.1164/rccm.201305-0898ED)

    Article  Google Scholar 

  9. Weitsman T, Weisz G, Farkash R, Klutstein M, Butnaru A, Rosenmann D, Hasin T. Pulmonary hypertension with left heart disease: prevalence, temporal shifts in etiologies and outcome. American Journal of Medicine 2018130 1272–1279. (https://doi.org/10.1016/j.amjmed.2017.05.003)

    Article  Google Scholar 

  10. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Gomez Sanchez MA, Krishna Kumar R, Landzberg M, Machado RF, et al. Updated clinical classification of pulmonary hypertension. Journal of the American College of Cardiology 201362 D34. (https://doi.org/10.1016/j.jacc.2013.10.029)

    Article  Google Scholar 

  11. D’Alto M, Romeo E, Argiento P, D’Andrea A, Vanderpool R, Correra A, Bossone E, Sarubbi B, Calabrò R, Russo MG, et al. Accuracy and precision of echocardiography versus right heart catheterization for the assessment of pulmonary hypertension. International Journal of Cardiology 2017168 4058–4062. (https://doi.org/10.1016/j.ijcard.2013.07.005)

    Article  Google Scholar 

  12. Rich JD, Shah SJ, Swamy RS, Kamp A, Rich S. Inaccuracy of Doppler echocardiographic estimates of pulmonary artery pressures in patients with pulmonary hypertension. Chest 2017139 988–993. (https://doi.org/10.1378/chest.10-1269)

    Article  Google Scholar 

  13. Fisher MR, Forfia PR, Chamera E, Housten-Harris T, Champion HC, Girgis RE, Corretti MC, Hassoun PM. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. American Journal of Respiratory and Critical Care Medicine 2009179 615–621. (https://doi.org/10.1164/rccm.200811-1691OC)

    Article  Google Scholar 

  14. Greiner S, Jud A, Aurich M, Hess A, Hilbel T, Hardt S, Katus HA, Mereles D. Reliability of noninvasive assessment of systolic pulmonary artery pressure by Doppler echocardiography compared to right heart catheterization: analysis in a large patient population. Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease 20143 e001103. (https://doi.org/10.1161/JAHA.114.001103)

    Article  Google Scholar 

  15. Roberts JD, Forfia PR. Diagnosis and assessment of pulmonary vascular disease by Doppler echocardiography. Pulmonary Circulation 20111 160–181. (https://doi.org/10.4103/2045-8932.83446)

    Article  Google Scholar 

  16. Magnino C, Omedè P, Avenatti E, Presutti D, Iannaccone A, Chiarlo M, Moretti C, Gaita F, Veglio F, Milan A, et al. Inaccuracy of right atrial pressure estimates through inferior vena cava indices. American Journal of Cardiology 2018120 1667–1673. (https://doi.org/10.1016/j.amjcard.2017.07.069)

    Article  Google Scholar 

  17. Fei B, Fan T, Zhao L, Pei X, Shu X, Fang X, Cheng L. Impact of severe tricuspid regurgitation on accuracy of systolic pulmonary arterial pressure measured by Doppler echocardiography: analysis in an unselected patient population. Echocardiography 201734 1082–1088. (https://doi.org/10.1111/echo.13555)

    Article  Google Scholar 

  18. Mukerjee D, St. George D, Knight C, Davar J, Wells AU, Du Bois RM, Black CM, Coghlan JG. Echocardiography and pulmonary function as screening tests for pulmonary arterial hypertension in systemic sclerosis. Rheumatology 200443 461–466. (https://doi.org/10.1093/rheumatology/keh067)

    CAS  Article  Google Scholar 

  19. Caballero L, Kou S, Dulgheru R, Gonjilashvili N, Athanassopoulos GD, Barone D, Cardim N, Gomez de Diego JJ, Oliva MJ, Hagendorff A, et al. Echocardiographic reference ranges for normal cardiac Doppler data: results from the NORRE Study. European Heart Journal: Cardiovascular Imaging 201516 1031–1041. (https://doi.org/10.1093/ehjci/jev083)

    Google Scholar 

  20. Schneider M, Pistritto AM, Gerges C, Gerges M, Binder C, Lang I, Maurer G, Binder T, Goliasch G. Multi-view approach for the diagnosis of pulmonary hypertension using transthoracic echocardiography. International Journal of Cardiovascular Imaging 201734 695–700. (https://doi.org/10.1007/s10554-017-1279-8)

    Google Scholar 

  21. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. Journal of the American Society of Echocardiography 201723 685–713. (https://doi.org/10.1016/j.echo.2010.05.010)

    Article  Google Scholar 

  22. McQuillan BM, Picard MH, Leavitt M, Weyman AE. Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circulation 2001104 2797. (https://doi.org/10.1161/hc4801.100076)

    CAS  Article  Google Scholar 

  23. Kitabatake A, Inoue M, Asao M, Masuyama T, Tanouchi J, Morita T, Mishima M, Uematsu M, Shimazu T, Hori M, et al. Noninvasive evaluation of pulmonary hypertension by a pulsed Doppler technique. Circulation 198368 302. (https://doi.org/10.1161/01.CIR.68.2.302)

    CAS  Article  Google Scholar 

  24. Howard LS, Grapsa J, Dawson D, Bellamy M, Chambers JB, Masani ND, Nihoyannopoulos P, Simon R, Gibbs J. Echocardiographic assessment of pulmonary hypertension: standard operating procedure. European Respiratory Review 201221 239–248. (https://doi.org/10.1183/09059180.00003912)

    Article  Google Scholar 

  25. Mallery JA, Gardin JM, King SW, Ey S, Henry WL. Effects of heart rate and pulmonary artery pressure on Doppler pulmonary artery acceleration time in experimental acute pulmonary hypertension. Chest 2018100 470–473. (https://doi.org/10.1378/chest.100.2.470)

    Article  Google Scholar 

  26. Parasuraman S, Walker S, Loudon BL, Gollop ND, Wilson AM, Lowery C, Frenneaux MP. Assessment of pulmonary artery pressure by echocardiography: a comprehensive review. International Journal of Cardiology: Heart and Vasculature 201612 45–51. (https://doi.org/10.1016/j.ijcha.2016.05.011)

    PubMed  PubMed Central  Google Scholar 

  27. Marra AM, Benjamin N, Ferrara F, Vriz O, D’Alto M, D’Andrea A, Stanziola AA, Gargani L, Cittadini A, Grünig E, et al. Reference ranges and determinants of right ventricle outflow tract acceleration time in healthy adults by two-dimensional echocardiography. International Journal of Cardiovascular Imaging 201733 219–226. (https://doi.org/10.1007/s10554-016-0991-0)

    Article  Google Scholar 

  28. Arkles JS, Opotowsky AR, Ojeda J, Rogers F, Liu T, Prassana V, Marzec L, Palevsky HI, Ferrari VA, Forfia PR. Shape of the right ventricular Doppler envelope predicts hemodynamics and right heart function in pulmonary hypertension. American Journal of Respiratory and Critical Care Medicine 2011183 268–276. (https://doi.org/10.1164/rccm.201004-0601OC)

    Article  Google Scholar 

  29. Ryan T, Petrovic O, Dillon JC, Feigenbaum H, Conley MJ, Armstrong WF. An echocardiographic index for separation of right ventricular volume and pressure overload. Journal of the American College of Cardiology 19855 918–927. (https://doi.org/10.1016/S0735-1097(85)80433-2)

    CAS  Article  Google Scholar 

  30. Austin C, Alassas K, Burger C, Safford R, Pagan R, Duello K, Kumar P, Zeiger T, Shapiro B. Echocardiographic assessment of estimated right atrial pressure and size predicts mortality in pulmonary arterial hypertension. Chest 2014147 198–208. (https://doi.org/10.1378/chest.13-3035)

    Article  Google Scholar 

  31. Bossone E, D’Andrea A, D’Alto M, Citro R, Argiento P, Ferrara F, Cittadini A, Rubenfire M, Naeije R. Echocardiography in pulmonary arterial hypertension: from diagnosis to prognosis. Journal of the American Society of Echocardiography 201326 1–14. (https://doi.org/10.1016/j.echo.2012.10.009)

    Article  Google Scholar 

  32. Grapsa J, Pereira Nunes MC, Tan TC, Cabrita IZ, Coulter T, Smith BCF, Dawson D, Gibbs JSR, Nihoyannopoulos P. Echocardiographic and hemodynamic predictors of survival in precapillary pulmonary hypertension. Clinical perspective. Circulation: Cardiovascular Imaging 20158 e002107. (https://doi.org/10.1161/CIRCIMAGING.114.002107)

    Google Scholar 

  33. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography 201528 1.e14–39.e14. (https://doi.org/10.1016/j.echo.2014.10.003)

    Article  Google Scholar 

  34. Weatherald J, Boucly A, Chemla D, Savale L, Peng M, Jevnikar M, Jaïs X, Taniguchi Y, O’Connell C, Parent F, et al. Prognostic value of follow-up hemodynamic variables after initial management in pulmonary arterial hypertension. Circulation 2018137 693–704. (https://doi.org/10.1161/CIRCULATIONAHA.117.029254)

    Article  Google Scholar 

  35. Abbas AE, Fortuin FD, Schiller NB, Appleton CP, Moreno CA, Lester SJ. A simple method for noninvasive estimation of pulmonary vascular resistance. Journal of the American College of Cardiology 200341 1021–1027. (https://doi.org/10.1016/S0735-1097(02)02973-X)

    Article  Google Scholar 

  36. Berger M, Haimowitz A, Van Tosh A, Berdoff RL, Goldberg E. Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound. Journal of the American College of Cardiology 19856 359–365. (https://doi.org/10.1016/S0735-1097(85)80172-8)

    CAS  Article  Google Scholar 

  37. Platts DG, Vaishnav M, Burstow DJ, Craig CH, Chan J, Sedgwick JF, Scalia GM. Contrast microsphere enhancement of the tricuspid regurgitant spectral Doppler signal: is it still necessary with contemporary scanners? International Journal of Cardiology: Heart and Vasculature 201717 1–10. (https://doi.org/10.1016/j.ijcha.2017.08.002)

    PubMed  PubMed Central  Google Scholar 

  38. Rosenkranz S, Gibbs JS, Wachter R, De Marco T, Vonk-Noordegraaf A, Vachiery JL. Left ventricular heart failure and pulmonary hypertension. European Heart Journal 201537 942–954. (https://doi.org/10.1093/eurheartj/ehv512)

    Article  Google Scholar 

  39. D’Alto M, Romeo E, Argiento P, Pavelescu A, Melot C, D’Andrea A, Correra A, Bossone E, Calabro R, Russo MG. Echocardiographic prediction of pre- versus postcapillary pulmonary hypertension. Journal of the American Society of Echocardiography 201728 108–115. (https://doi.org/10.1016/j.echo.2014.09.004)

    Article  Google Scholar 

  40. Opotowsky AR, Ojeda J, Rogers F, Prasanna V, Clair M, Moko L, Vaidya A, Afilalo J, Forfia PR. A simple echocardiographic prediction rule for hemodynamics in pulmonary hypertension clinical perspective. Circulation: Cardiovascular Imaging 20125 765.

    Google Scholar 

  41. Ghoreishi M, Evans CF, DeFilippi CR, Hobbs G, Young CA, Griffith BP, Gammie JS. Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: Implications for timing of surgery. Journal of Thoracic and Cardiovascular Surgery 2011142 1439–1452. (https://doi.org/10.1016/j.jtcvs.2011.08.030)

    Article  Google Scholar 

  42. Mentias A, Patel K, Patel H, Gillinov AM, Sabik JF, Mihaljevic T, Suri RM, Rodriquez LL, Svensson LG, Griffin BP, et al. Effect of pulmonary vascular pressures on long-term outcome in patients with primary mitral regurgitation. Journal of the American College of Cardiology 201667 2952–2961. (https://doi.org/10.1016/j.jacc.2016.03.589)

    Article  Google Scholar 

Download references

Funding

The publication of this article was sponsored by Actelion Pharmaceuticals Ltd. The article was produced by the British Society of Echocardiography independently of Actelion Pharmaceuticals Ltd, and they were not able to influence its content. Peer review was carried out independently by the journal’s editorial board, based on scientific merit alone.

Author information

Authors and Affiliations

  1. Royal United Hospital Bath NHS Foundation Trust, Bath, UK

    Daniel X. Augustine MD & James Willis PhD

  2. Nottingham University Hospitals NHS Trust, Nottingham, UK

    Lindsay D. Coates-Bradshaw & Thomas Mathew

  3. Colchester Hospital NHS Trust, Colchester, UK

    Allan Harkness MSc

  4. West Suffolk Hospital NHS Trust, Bury St Edmonds, UK

    Liam Ring

  5. Hammersmith Hospital, Imperial College London, London, UK

    Julia Grapsa PhD

  6. Royal Free London NHS Foundation Trust–Cardiology, London, UK

    Gerry Coghlan MD

  7. West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK

    Nikki Kaye

  8. Liverpool John Moores University, Research Institute for Sports and Exercise Physiology, Liverpool, UK

    David Oxborough PhD

  9. Papworth Hospital NHS Foundation Trust, Cambridge, UK

    Shaun Robinson MSc

  10. Leeds Teaching Hospitals NHS Trust, Leeds, UK

    Julie Sandoval

  11. Papworth Hospital, Cambridge, UK

    Bushra S. Rana FRCP

  12. Queen Alexandra Hospital, Portsmouth, UK

    Anjana Siva

  13. Imperial College London, NHLI, National Heart & Lung Institute, London, UK

    Petros Nihoyannopoulos MD

  14. Imperial College London, National Pulmonary Hypertension Service, London, UK

    Luke S. Howard DPhil

  15. Hammersmith Hospital, London, UK

    Kevin Fox FRCP

  16. St Bartholomew’s Hospital, Barts’ Heart Centre, London, UK

    Sanjeev Bhattacharyya MD

  17. Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK

    Vishal Sharma MD

  18. University Hospital Birmingham and University of Birmingham, Birmingham, UK

    Richard P. Steeds MD

Authors
  1. Daniel X. Augustine MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lindsay D. Coates-Bradshaw
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. James Willis PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Allan Harkness MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Liam Ring
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Julia Grapsa PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Gerry Coghlan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Nikki Kaye
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. David Oxborough PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Shaun Robinson MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Julie Sandoval
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Bushra S. Rana FRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Anjana Siva
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Petros Nihoyannopoulos MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Luke S. Howard DPhil
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Kevin Fox FRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Sanjeev Bhattacharyya MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Vishal Sharma MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Richard P. Steeds MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Thomas Mathew
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel X. Augustine MD.

Additional information

(D Augustine is the Lead Author)

(Guideline Chairs: T Mathew and V Sharma)

The publication of this article was sponsored by Actelion Pharmaceuticals Ltd. The article was produced by the British Society of Echocardiography independently of Actelion Pharmaceuticals Ltd and they were not able to influence its content. Peer review was carried out independently by the journal’s editorial board, based on scientific merit alone.

Rights and permissions

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Augustine, D.X., Coates-Bradshaw, L.D., Willis, J. et al. Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Res Pract 5, G11–G24 (2018). https://doi.org/10.1530/ERP-17-0071

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-17-0071

Key Words

  • pulmonary hypertension
  • echocardiography
  • guideline

Echo Research & Practice

ISSN: 2055-0464