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Original Research: Pulmonary Vascular Disease |

Exercise Stress Echocardiography of the Pulmonary CirculationLimits of Normal in the Pulmonary Circulation: Limits of Normal and Sex Differences

Paola Argiento, MD; Rebecca R. Vanderpool, PhD; Massimiliano Mulè, MD; Maria Giovanna Russo, MD; Michele D’Alto, MD; Eduardo Bossone, MD; Naomi C. Chesler, PhD; Robert Naeije, MD
Author and Funding Information

From the Department of Cardiology (Drs Argiento, Russo, and D’Alto), Second University of Naples, Naples, Italy; the Clinical Division of Cardiology (Dr Mulè), Ferrarotto Hospital, University of Catania, Catania, Italy; the Department of Cardiac Surgery (Dr Bossone), IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; the Department of Biomedical Engineering (Dr Chesler), University of Wisconsin-Madison, Madison, WI; and the Department of Physiology (Drs Vanderpool and Naeije), Faculty of Medicine, Free University of Brussels, Brussels, Belgium.

Correspondence to: Robert Naeije, MD, Department of Physiology, Faculty of Medicine, Free University of Brussels, Erasme Campus CP 604, 808 Lennik Rd, 1070 Brussels, Belgium; e-mail: rnaeije@ulb.ac.be

Drs Argiento and Vanderpool contributed equally to this article.


Funding/Support: This work was supported by the National Institutes of Health [1R01HL105598 to NCC], the Funds for Cardiac Surgery [to R. N.], the Fonds de la Recherche Scientifique Médicale [3.4637.09 to R. N.], and the Bureau for International Relations and Cooperation [to R. R. V.].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(5):1158-1165. doi:10.1378/chest.12-0071
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Background:  Exercise stress echocardiography has not been recommended in the diagnostic workup of pulmonary hypertension because of insufficient certainty about feasibility and limits of normal.

Methods:  Doppler echocardiography pulmonary hemodynamic measurements were performed at a progressively increased workload in 56 healthy male and 57 healthy female volunteers aged 19 to 63 years. Mean pulmonary artery pressure (mPAP) was estimated from the maximal tricuspid regurgitation jet velocity. Cardiac index was calculated from the left ventricular outflow velocity-time integral. Pulmonary vascular distensibility α index, the percentage change of vessel diameter per mm Hg of mPAP, was calculated from multipoint mPAP-cardiac output (CO) plots.

Results:  Peak exercise at 175 ± 50 W was associated with an mPAP of 33 ± 7 mm Hg and a CO of 18 ± 5 L/min. The slope of mPAP-CO relationships was 1.5 ± 0.5 mm Hg/L/min, and the distensibility coefficient (α) was 1.3% ± 1.0%/mm Hg. Maximal workload and cardiac index were higher in men than in women (P < .05), but mPAP-cardiac index relationships were not different. However, women had a higher α (1.6% ± 1.3%/mm Hg vs 1.1% ± 0.6%/mm Hg, P < .05). The average mPAP-cardiac index slope was higher and α lower in subjects ≥ 50 years old. Upper limits of normal of mPAP at exercise were 34 mm Hg at a CO < 10 L/min, 45 mm Hg at a CO < 20 L/min, and 52 mm Hg at a CO < 30 L/min. These values are in keeping with previously reported invasive measurements.

Conclusions:  Exercise stress echocardiography of the pulmonary circulation is feasible and allows for flow-corrected definition of upper limits of normal. Women have a more distensible pulmonary circulation.

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