Variability in hemodynamic evaluation of pulmonary hypertension at large referral centers

Abstract

Despite consensus guidelines for right heart catheterization (RHC) in the diagnosis of pulmonary arterial hypertension (PAH), considerable differences exist in the performance of RHC, interpretation of hemodynamic data, and frequency of RHC performance in patients with established disease. These differences may lead to variability in diagnosis or treatment of PAH. We sought to gather information on the standard practice of RHC for the diagnosis and management of PAH from experienced pulmonary vascular disease specialists. We developed a semiquantitative online survey of diagnosis and treatment patterns of pulmonary hypertension and distributed it to physicians at pulmonary hypertension centers in the United States. Thirty of 50 physicians completed the survey: 20 pulmonologists and 10 cardiologists, all of whom reported treating >100 patients with PAH in the past year. All respondents perform RHC in ≥90% of patients with suspected PAH. All physicians determine the pulmonary wedge pressure at end expiration; however, only half of respondents personally review tracings. Physicians differed in frequency of vasodilator testing (8 of 24 performed testing in >90% of patients with PAH), fluid challenge and exercise (19 of 30 performed testing in <25% of patients with PAH for both). Most physicians (70%) report repeating RHC between 6 months and 1 year after PAH treatment initiation. Variability exists in the interpretation of hemodynamic tracings and performance of vasodilator, fluid, and exercise challenges in the management of PAH by experienced physicians in the United States. Additional consensus guidelines delineating appropriate adjunctive testing to standardize the diagnosis of PAH are needed.