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Correspondence |

Latent Pulmonary Hypertension: Looking Beyond the Scene FREE TO VIEW

Eduardo Bossone, MD, PhD, FCCP; Rodolfo Citro, MD; William F. Armstrong, MD; Melvyn Rubenfire, MD
Author and Funding Information

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: ebossone@hotmail.com



Chest. 2008;134(2):469-470. doi:10.1378/chest.08-0640
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To the Editor:

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.14

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.67

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.14,6,811

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.

Huez, S, Naeije, R (2007) Exercise stress tests for detection and evaluation of pulmonary hypertension.Eur Heart J9,H17-H21. [CrossRef]
 
Vachiéry, JL, Pavelescu, A Exercise echocardiography in pulmonary hypertension.Eur Heart J2007;9,H48-H53
 
Bossone, E, Bodini, BD, Mazza, A, et al Pulmonary arterial hypertension: the key role of echocardiography.Chest2005;127,1836-1843. [PubMed]
 
McGoon, M, Gutterman, D, Steen, V, et al Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.Chest2004;126,14S-34S. [PubMed]
 
McQullian, BM, Picard, MH, Leawitt, M, et al Clinical correlates and reference intervals for pulmonary artery pressure among echocardiographically normal subjects.Circulation2001;104,2797-2802. [PubMed]
 
Bossone, E, Rubenfire, M, Bach, DS, et al Range of tricuspid regurgitation velocity at rest and during exercise in normal adult men: implications for the diagnosis of pulmonary hypertension.J Am Coll Cardiol1999;33,1662-1666. [PubMed]
 
West, JB Left ventricular filling pressures during exercise: a cardiological blind spot?Chest1998;113,1695-1697. [PubMed]
 
Kiencke, S, Bernheim, A, Maggiorini, M, et al Exercise induced pulmonary arterial hypertension: a rare finding.J Am Coll Cardiol2008;29,513-518
 
Bernheim, AM, Kiencke, S, Fischler, M, et al Acute changes in pulmonary artery pressures due to exercise and exposure to high altitude do not cause left ventricular diastolic dysfunction.Chest2007;132,380-387. [PubMed]
 
Bossone, E, Citro, R, Blasi, F, et al Echocardiography in pulmonary arterial hypertension: an essential tool.Chest2007;131,339-341. [PubMed]
 
Grunig, E, Janssen, B, Mereles, D, et al Abnormal pulmonary artery pressure response in asymptomatic carriers of primary pulmonary hypertension gene.Circulation2000;102,1145-1150. [PubMed]
 

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References

Huez, S, Naeije, R (2007) Exercise stress tests for detection and evaluation of pulmonary hypertension.Eur Heart J9,H17-H21. [CrossRef]
 
Vachiéry, JL, Pavelescu, A Exercise echocardiography in pulmonary hypertension.Eur Heart J2007;9,H48-H53
 
Bossone, E, Bodini, BD, Mazza, A, et al Pulmonary arterial hypertension: the key role of echocardiography.Chest2005;127,1836-1843. [PubMed]
 
McGoon, M, Gutterman, D, Steen, V, et al Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.Chest2004;126,14S-34S. [PubMed]
 
McQullian, BM, Picard, MH, Leawitt, M, et al Clinical correlates and reference intervals for pulmonary artery pressure among echocardiographically normal subjects.Circulation2001;104,2797-2802. [PubMed]
 
Bossone, E, Rubenfire, M, Bach, DS, et al Range of tricuspid regurgitation velocity at rest and during exercise in normal adult men: implications for the diagnosis of pulmonary hypertension.J Am Coll Cardiol1999;33,1662-1666. [PubMed]
 
West, JB Left ventricular filling pressures during exercise: a cardiological blind spot?Chest1998;113,1695-1697. [PubMed]
 
Kiencke, S, Bernheim, A, Maggiorini, M, et al Exercise induced pulmonary arterial hypertension: a rare finding.J Am Coll Cardiol2008;29,513-518
 
Bernheim, AM, Kiencke, S, Fischler, M, et al Acute changes in pulmonary artery pressures due to exercise and exposure to high altitude do not cause left ventricular diastolic dysfunction.Chest2007;132,380-387. [PubMed]
 
Bossone, E, Citro, R, Blasi, F, et al Echocardiography in pulmonary arterial hypertension: an essential tool.Chest2007;131,339-341. [PubMed]
 
Grunig, E, Janssen, B, Mereles, D, et al Abnormal pulmonary artery pressure response in asymptomatic carriers of primary pulmonary hypertension gene.Circulation2000;102,1145-1150. [PubMed]
 
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