Should Patients With Connective Tissue Disease Undergo Exercise Doppler Echocardiography?

Abstract

We read with the great interest the recently published article by Kovacs et al1Kovacs G Maier R Aberer E et al.Assessment of pulmonary arterial pressure during exercise in collagen vascular disease: echocardiography vs right-sided heart catheterization.Chest. 2010; 138: 270-278Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar (August 2010) indicating that exercise Doppler echocardiography (EDE) can be a useful, noninvasive screening tool to detect an increase in systolic pulmonary artery pressure (PAP) during exercise in patients with connective tissue disease. However, in our opinion, there are some interesting issues to be discussed. According to the recent European Society of Cardiology guidelines on pulmonary hypertension (PH), the definition of PH on exercise is not supported by published data.2Galiè N Hoeper MM Humbert M Authors/Task Force Members ESC Committee for Practice Guidelines (CPG) Document Reviewers et al.Guidelines for the diagnosis and treatment of pulmonary hypertension.Eur Heart J. 2009; 30: 2493-2537Crossref PubMed Scopus (2794) Google Scholar Thus, no definition of exercise-induced PH can be provided currently. Moreover, US guidelines are consistent with this statement.3McLaughlin VV Archer SL Badesch DB American College of Cardiology Foundation Task Force on Expert Consensus Documents American Heart Association American College of Chest Physicians American Thoracic Society, Inc Pulmonary Hypertension Association et al.ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association.J Am Coll Cardiol. 2009; 53: 1573-1619Abstract Full Text Full Text PDF PubMed Scopus (1317) Google Scholar However, recently published data indicate that more attention should be paid to an exaggerated increase of systolic PAP during exercise, which is suggested to be a marker of early pulmonary vasculopathy in connective tissue disease. Kovacs et al1Kovacs G Maier R Aberer E et al.Assessment of pulmonary arterial pressure during exercise in collagen vascular disease: echocardiography vs right-sided heart catheterization.Chest. 2010; 138: 270-278Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar revealed that EDE showed a systolic PAP >40 mm Hg during exercise in 26 of 52 patients with connective tissue disease. In our unpublished observations, an increase in systolic PAP of >20 mm Hg at EDE was recorded in 11 (17%) of 65 patients with systemic sclerosis. In all of the 11 patients with increased systolic PAP, subsequent right-sided heart catheterization (RHC) confirmed systolic PAP increase during exercise. In our opinion, EDE is a potentially useful test to detect “exercise-induced PH” that may represent an intermediate stage between a physiologic response and manifest PH. Importantly, an elevated systolic PAP on exercise can be caused not only by pulmonary vasculopathy but also by a significant increase in pulmonary venous pressure. Among patients reported by Kovacs et al,1Kovacs G Maier R Aberer E et al.Assessment of pulmonary arterial pressure during exercise in collagen vascular disease: echocardiography vs right-sided heart catheterization.Chest. 2010; 138: 270-278Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar RHC revealed an elevation of pulmonary arterial wedge pressure >20 mm Hg in 33% of subjects with exercise-induced PAP increase. In our group of 16 patients with systemic sclerosis (11 subjects with exercise-induced PH and five with PH at rest), RHC showed an elevated pulmonary arterial wedge pressure in 12 (75%) of them. These findings may suggest a latent left-ventricular filling dysfunction. Interestingly, these observations suggest that left-ventricular diastolic dysfunction in patients with connective tissue disease is more frequent than previously believed. Our data indicate that left-ventricular preload reduction using small doses of diuretics may be beneficial for such patients. In our opinion, Kovacs et al1Kovacs G Maier R Aberer E et al.Assessment of pulmonary arterial pressure during exercise in collagen vascular disease: echocardiography vs right-sided heart catheterization.Chest. 2010; 138: 270-278Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar are perfectly right that EDE is a useful, noninvasive method to detect systolic PAP increase during exercise in patients with connective tissue disease. However, it should be remembered that RHC still remains the golden standard for assessment of PH. Should Patients With Connective Tissue Disease Undergo Exercise Doppler Echocardiography?: ResponseCHESTVol. 138Issue 6PreviewWe appreciate the comment by Dr Ciurzyński et al concerning our recently published data (August 2010)1 on the potential role of exercise Doppler echocardiography (EDE) as a noninvasive screening tool. We also appreciate the agreement of Dr Ciurzyński et al with our main statements and that their unpublished data support our results. Full-Text PDF