It is often said that perfect is the enemy of good. A disease screening procedure can never be perfect and almost always represents a balance between positive and negative predictive values while factoring in patient risk and costs to society. Although physicians are taught to strive for perfect, when balancing the aforementioned, we must strive for good enough.
Pulmonary hypertension (PH) often represents a diagnostic challenge when relying on bedside tools, including history and physical examination. It is, however, a serious hemodynamic consequence of a variety of medical conditions and imparts significant morbidity and reduced life span when severe. Although right-sided heart catheterization (RHC) is required to confirm a diagnosis of PH, it is apparent that performing RHC on all patients with dyspnea would be costly, bear excessive risk, and be impractical in our current cost-constrained environment. We are better served by a noninvasive test that provides a compromise among accuracy, safety, simplicity, and cost. Echocardiography provides this combination. Appropriate Use Criteria consider echocardiography appropriate as the initial study in the workup of suspected PH and any patient with dyspnea and a suspected cardiac etiology.1