The study by Rich et al1 strengthens the voice of common sense, which apparently needs amplification. It is important to make two additional points. First, RHC is not by itself the gold standard for the diagnosis of PAH; it is only as good as the people who perform and interpret it. Often, it is not performed appropriately, even in tertiary-care centers by cardiologists. A PAWP inappropriately recorded by 5 or 10 mm Hg is enough to completely misdiagnose the condition and mislead the therapy.8,9 Second, at the same time, we should not ignore the possibility that although TRV may not be as useful an index as believed, there are other parameters that even a simple standard echocardiogram can provide. For example, there are indications that other Doppler-based parameters (eg, pulmonary artery acceleration time [PAAT]) can be used to estimate mPAP10 (Fig 1). Unfortunately, Rich et al1 did not provide such data. Could PAAT, as a predictor of mPAP, be a better predictor of true PAH or PVR? Other, equally easy-to-obtain DE formulas and parameters have been developed to predict PVR, and it will be important to examine whether these are better than TRV as a screening test. There is no question that as ECHO research is advancing, it will remain a mainstay in the assessment of patients with PAH. Comprehensive ECHO assessment using parameters that can estimate mPAP or PVR in combination with tools that can measure right ventricular function (like the tricuspid annular plane systolic excursion technique11) needs to be studied carefully in PAH cohorts.