Affiliations: Department of Cardiorespiratory Disease, University of Milan, Milan, Italy,
Echocardiography Laboratory, San Luca Hospital, Salerno, Italy,
Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
Correspondence to: Eduardo Bossone, MD, PhD, FCCP, Dipartimento Cardiorespiratorio, Università degli Studi di Milano, Padiglione Sacco, Ospedale Maggiore Milano, IRCCS Fondazione Policlinico-Mangiagalli-Regina Elena, via F. Sforza 35, 20122 Milan Italy; e-mail: firstname.lastname@example.org
Although many noninvasive laboratories are introducing exercise Doppler echocardiography (Ex-Echo) as a standard technique to unmask latent or presymptomatic pulmonary hypertension (exercise-induced pulmonary hypertension [Ex-PHtn]), several important issues need redress.1–4
1. A consensus should be reached on the optimal exercise protocol (treadmill vs supine/upright/semirecumbent bicycle) to be implemented since each protocol is characterized by different loading conditions. At the present time, semirecumbent exercise echocardiography appears to be more suitable for reliable and reproducible echo-Doppler measurements considering that measures are made during exercise and recovery.
2. There is a need to define the full physiologic range of pulmonary pressure responses to both bicycle and treadmill exercise in relation to age, gender, body mass index, and level of physical training.5In highly trained athletes, a high workload is associated with moderate increases in pulmonary artery systolic pressure as a direct consequence of increased stroke volume and left ventricular filling pressures.6–7
3. An emerging question is who to screen for Ex-PHtn, knowing the yield of a screening examinations depends not only on the sensitivity and specificity of the test employed, but also on the prevalence of the disease (pretest probability) in the study population. Current data report the presence of Ex-PHtn in COPD, heart transplantation, susceptibility to high-altitude pulmonary edema, congenital heart disease, thromboembolic pulmonary hypertension, scleroderma, and relatives of patients with pulmonary arterial hypertension. However, the actual prevalence and clinical value (early stage disease?) of Ex-PHtn in the wide spectrum of conditions involving the cardiorespiratory system remain not fully explored.1–4,6,8–11
4. Well-designed longitudinal studies are warranted to investigate the natural history of pulmonary hypertension and whether preclinical treatment can prevent the development of more severe forms of pulmonary vascular disease in susceptible persons. Ex-PHtn remains a fascinating clinical condition and Ex-echo a versatile tool “to look beyond the scene” of otherwise unexplained effort dyspnea.
The authors have no conflicts of interest to disclose.
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