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Gabor Kovacs, MD; Horst Olschewski, MD, FCCP
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From the Department of Pulmonology, Medical University Graz.

Correspondence to: Gabor Kovacs, MD, Medical University Graz–Pulmonology, Auenbruggerplatz 20, Graz 8044, Austria; e-mail: gabor.kovacs@klinikum-graz.at


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Kovacs has received pharmaceutical company grant monies from Actelion Austria GmbH, as well as travel accommodations and speaking honoraria from multiple pharmaceutical companies, including Actelion, GlaxoSmithKline, Astra Zeneca, and Bayer-Schering Pharma. Dr Olschewski received university, European Union, and pharmaceutical industry grant monies and royalties from Actelion, Pfizer, Bayer-Schering Pharma, and GlaxoSmithKline. Dr Olschewski also is a consultant to Unither, Novartis, and Bayer-Schering Pharma, and had speaking activities for Actelion, Bayer-Schering Pharma, GlaxoSmithKline, Pfizer, and Unither.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(6):1524. doi:10.1378/chest.10-1740
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To the Editor:

We 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 We also appreciate the agreement of Dr Ciurzyński et al with our main statements and that their unpublished data support our results.

We agree that currently no definition of exercise-induced pulmonary hypertension (PH) exists.2,3 This does not imply that exercise-induced pulmonary artery pressure (PAP) changes are clinically irrelevant. We need more data providing us with evidence for a reintroduction of a new definition of exercise-induced PH.

We also agree that an exaggerated increase of PAP during exercise may be a sign of early pulmonary vasculopathy and may represent an intermediate stage between a physiologic response and manifest PH. This has already been discussed in a recent article by Tolle et al.4 According to our own results, an out-of-proportion PAP increase at low exercise levels may be especially clinically relevant.5

We also agree that besides pulmonary vasculopathy, a PAP increase during exercise may be triggered by other factors, such as a diastolic dysfunction of the left ventricle. This question is also discussed in our article. According to the unpublished data mentioned by Ciurzyński et al, an elevated pulmonary arterial wedge pressure was found in a very large proportion (75%) of their patients with scleroderma with manifest PAH or exercise-induced PAP increase. We found an elevated pulmonary arterial wedge pressure increase in “just”33%. This discrepancy may be caused by different methods, different definitions, different patient characteristics, or by chance. A larger prospective study would be necessary to answer the question of how frequently a left ventricular filling dysfunction occurs and on what it depends. The methods applied by Ciurzyński et al are similar to a previous article by Steen et al6 (positive response: increase of at least 20 mm Hg in the right ventricular systolic pressure with exercise), although the data here also show some differences (positive cases 44% in Steen et al vs 17% in Ciurzyński et al).

Despite this variety of the data, the main message remains the same for all the studies, as we also state in the conclusion of our article—that EDE may serve as a useful screening tool for exercise-induced PAP increase, but that right-sided heart catheterization remains the gold standard for the diagnosis of PH.

Kovacs 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;1382:270-278. [CrossRef] [PubMed]
 
Galiè N, Hoeper MM, Humbert M, et al; Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC) Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC) European Respiratory Society (ERS) European Respiratory Society (ERS) International Society of Heart and Lung Transplantation (ISHLT) International Society of Heart and Lung Transplantation (ISHLT) Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2009;346:1219-1263. [CrossRef] [PubMed]
 
Kovacs G, Berghold A, Scheidl S, Olschewski H. Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review. Eur Respir J. 2009;344:888-894. [CrossRef] [PubMed]
 
Tolle JJ, Waxman AB, Van Horn TL, Pappagianopoulos PP, Systrom DM. Exercise-induced pulmonary arterial hypertension. Circulation. 2008;11821:2183-2189. [CrossRef] [PubMed]
 
Kovacs G, Maier R, Aberer E, et al. Borderline pulmonary arterial pressure is associated with decreased exercise capacity in scleroderma. Am J Respir Crit Care Med. 2009;1809:881-886. [CrossRef] [PubMed]
 
Steen V, Chou M, Shanmugam V, Mathias M, Kuru T, Morrissey R. Exercise-induced pulmonary arterial hypertension in patients with systemic sclerosis. Chest. 2008;1341:146-151. [CrossRef] [PubMed]
 

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References

Kovacs 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;1382:270-278. [CrossRef] [PubMed]
 
Galiè N, Hoeper MM, Humbert M, et al; Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC) Task Force for Diagnosis and Treatment of Pulmonary Hypertension of European Society of Cardiology (ESC) European Respiratory Society (ERS) European Respiratory Society (ERS) International Society of Heart and Lung Transplantation (ISHLT) International Society of Heart and Lung Transplantation (ISHLT) Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2009;346:1219-1263. [CrossRef] [PubMed]
 
Kovacs G, Berghold A, Scheidl S, Olschewski H. Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review. Eur Respir J. 2009;344:888-894. [CrossRef] [PubMed]
 
Tolle JJ, Waxman AB, Van Horn TL, Pappagianopoulos PP, Systrom DM. Exercise-induced pulmonary arterial hypertension. Circulation. 2008;11821:2183-2189. [CrossRef] [PubMed]
 
Kovacs G, Maier R, Aberer E, et al. Borderline pulmonary arterial pressure is associated with decreased exercise capacity in scleroderma. Am J Respir Crit Care Med. 2009;1809:881-886. [CrossRef] [PubMed]
 
Steen V, Chou M, Shanmugam V, Mathias M, Kuru T, Morrissey R. Exercise-induced pulmonary arterial hypertension in patients with systemic sclerosis. Chest. 2008;1341:146-151. [CrossRef] [PubMed]
 
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