Abstract
Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance, yet current two-dimensional echocardiographic methods are inadequate for the accurate estimation of this haemodynamic marker. Right-heart trans-tricuspid Doppler and tissue Doppler echocardiographic techniques can be combined to calculate the right ventricular (RV) E/e′ ratio – a reflection of RV filling pressure which is a surrogate of RAP. A systematic search was undertaken which found seventeen articles that compared invasively measured RAP with RV-E/e′ estimated RAP. Results commonly concerned pulmonary hypertension or advanced heart failure/transplantation populations. Reported receiver operating characteristic analyses showed reasonable diagnostic ability of RV-E/e′ for estimating RAP in patients with coronary artery disease and RV systolic dysfunction. The diagnostic ability of RV-E/e′ was generally poor in studies of paediatrics, heart failure and mitral stenosis, whilst results were equivocal in other diseases. Bland–Altman analyses showed good accuracy but poor precision of RV-E/e′ for estimating RAP, but were limited by only being reported in seven out of seventeen articles. This suggests that RV-E/e′ may be useful at a population level but not at an individual level for clinical decision making. Very little evidence was found about how atrial fibrillation may affect the estimation of RAP from RV-E/e′, nor about the independent prognostic ability of RV-E/e′ . Recommended areas for future research concerning RV-E/e′ include; non-sinus rhythm, valvular heart disease, short and long term prognostic ability, and validation over a wide range of RAP.
Highlights
Right atrial pressure (RAP) is a haemodynamic variable that provides important diagnostic and prognostic information in both cardiovascular and pulmonary disease patients (1, 2, 3)
Results obtained by our systematic search pertained to a variety of clinical situations, pathologies and patient demographics; the relationship between right ventricular (RV)-E/e′ and invasively measured RAP varied
Utsunomiya et al (15) found that in 50 patients with a range of aetiologies of pulmonary hypertension (PH), RV-E/e′ was positively correlated with mean RAP (r = 0.80, P < 0.001)
Summary
Right atrial pressure (RAP) is a haemodynamic variable that provides important diagnostic and prognostic information in both cardiovascular and pulmonary disease patients (1, 2, 3). Despite its usefulness in routine clinical assessment the gold-standard measurement technique remains invasive right-heart catheterisation (RHC), a procedure which requires radiation exposure, is associated with a degree of patient risk and is not available as a bedside test; RHC is, unsuitable for regular serial assessment. Accurate non-invasive alternatives to determining RAP are advantageous both clinically and for patient safety/experience; transthoracic echocardiography (TTE) offers one such method. Estimation of RAP is required during echocardiography to combine with measurements of tricuspid and pulmonary regurgitation velocities to estimate pulmonary artery pressures (4).
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