Precision of Echocardiographic Estimates of Right Atrial Pressure in Patients with Acute Decompensated Heart Failure

doi:10.1016/j.echo.2014.06.002

Journal of the American Society of Echocardiography

Volume 27, Issue 10, October 2014, Pages 1072-1078.e2

https://doi.org/10.1016/j.echo.2014.06.002 Get rights and content

Background

Several methods that estimate right atrial pressure (RAP) from echocardiographic parameters have been proposed. However, their precision (i.e., how much they decrease RAP estimation uncertainty) is unknown. The aim of this prospective study was to evaluate and compare the precision of previously proposed RAP estimates in patients with acute decompensated heart failure.

Methods

Echocardiographic and invasive hemodynamic data were acquired in 75 patients with acute decompensated heart failure. Measurements were made at the start and 48 to 72 hours after the beginning of treatment. RAP was estimated by method 1, using the cutoffs defined by inferior vena cava diameter (IVCd) and IVCd percentage change (IVCd%change) during inspiration, and by method 2, using IVCd%change and systolic to diastolic hepatic flow ratio (S/D_hep). Method 3 was used in patients with sinus rhythm, using the ratio of early tricuspid inflow and early diastolic tissue Doppler tricuspid annular velocities (E/E′_ta). RAP was also estimated by resting IVCd, IVCd during inspiration, IVCd%change, right ventricular regional isovolumetric relaxation time, E/E′_ta, right atrial volume index, S/D_hep, right ventricular Tei index, right ventricular E/A, and right atrial emptying fraction. Precision gain was measured as the difference between the standard deviation of RAP and the standard error of the estimate of RAP.

Results

Method 1 (r = 0.48, P < .05), IVCd during inspiration (r = 0.49, P < .0001), IVCd%change (r = 0.41, P < .0001) and IVCd (r = 0.40, P < .0001) had the highest correlation with RAP. The highest gain in precision was also observed with the above methods (9%, 13%, 9%, and 8%, respectively). All other parameters had poor correlation with RAP.

Conclusion

In patients with advanced heart failure, echocardiographic RAP prediction methods showed only modest precision. Furthermore, none of the tested methods resulted in clinically relevant improvements of RAP estimates. Estimating RAP from a single IVCd measurement is at least as precise as using complex prediction methods.

Section snippets

Study Population and Design

This was a prospective observational echocardiographic study of patients admitted to the Heart Failure Unit at the Cleveland Clinic for hemodynamically tailored treatment of acute decompensated systolic heart failure. We prospectively identified patients aged ≥18 years who were admitted to the heart failure intensive care unit at the Cleveland Clinic for pulmonary catheter–based therapy for acute decompensated systolic heart failure. The decision to treat patients in the intensive care unit was

Patient Characteristics

A total of 73 patients met the eligibility criteria during the study period. One patient was excluded because of poor echocardiographic windows, and another patient was excluded because of inadequate central venous pressure measurements. Overall, 123 hemodynamic measurements were performed (71 measurements at baseline and 52 measurements 48–72 hours after admission to the unit; in 19 patients, measurements were not repeated, because their clinical status improved to the point that the invasive

Discussion

The aim of any estimation is to decrease the initial uncertainty of the parameter assessed. In our study, the initial uncertainty range was decreased by only 8% using previously proposed methods, by 13% using linear regression analysis, and by 19% using a CART model. These improvements in uncertainty, although statistically significant, were modest and have limited clinical significance. In other words, prediction of RAP by echocardiography appears to have very limited precision in patients

Conclusions

In patients with advanced heart failure, the echocardiographic methods for evaluating RAP showed only modest precision. Furthermore, none of the previously proposed RAP prediction methods resulted in a clinically relevant improvement of RAP estimate precision. Estimating RAP from a single IVCd measurement was at least as precise as using proposed complex prediction methods. The CART algorithm detected a subgroup of patients with elevated RAP in 15% of cases but failed to differentiate between

Acknowledgments

The authors thank Kenya Kusunose, MD, for his help with figure editing and Kathryn Brock, BA, for editing the manuscript.

References (25)

L.G. Rudski et al.
Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography
J Am Soc Echocardiogr
(2010)
B.J. Kircher et al.
Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava
Am J Cardiol
(1990)
R. Beigel et al.
Noninvasive evaluation of right atrial pressure
J Am Soc Echocardiogr
(2013)
K.S. Lee et al.
Echocardiographic assessment of right heart hemodynamic parameters
J Am Soc Echocardiogr
(2007)
S. Fukuda et al.
Echocardiographic insights into atrial and ventricular mechanisms of functional tricuspid regurgitation
Am Heart J
(2006)
C. Tei et al.
Doppler echocardiographic index for assessment of global right ventricular function
J Am Soc Echocardiogr
(1996)
A. Abbas et al.
Noninvasive assessment of right atrial pressure using Doppler tissue imaging
J Am Soc Echocardiogr
(2004)
S.R. Ommen et al.
Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study
Mayo Clin Proc
(2000)
M.F. Nageh et al.
Estimation of mean right atrial pressure using tissue Doppler imaging
Am J Cardiol
(1999)
K.L. Chan et al.
Comparison of three Doppler ultrasound methods in the prediction of pulmonary artery pressure
J Am Coll Cardiol
(1987)

P.J. Currie et al.

Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler-catheterization study in 127 patients

J Am Coll Cardiol

(1985)

J.H. Stein et al.

Comparison of estimates of right atrial pressure by physical examination and echocardiography in patients with congestive heart failure and reasons for discrepancies

Am J Cardiol

(1997)

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This could be due to changes in hepatic vein flow associated with parenchymal fibrosis in patients with organic hepatic disorders.28 Incorporation of these secondary indices to refine RAP estimates did not improve IVC measurement precision.11,26 Therefore, further investigation is required for more reliable and feasible RAP estimation methods.
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Both systolic and diastolic SVC flow velocities were higher in the subcostal than in the supraclavicular approach, and effect of position change on subcostal SVC-S/D was smaller than that on supraclavicular SVC-S/D in healthy adults. Measurement of SVC-S/D from the subcostal window was feasible in 98 patients (85%). RAP was inversely correlated with SVC-S/D (r = −0.50, P < .001) and was an independent determinant of SVC-S/D after adjustment for right ventricular systolic function (β = −0.48, P < .001). A cutoff value of 1.9 for SVC-S/D showed 85% sensitivity and 74% specificity in identifying elevated RAP. Additionally, SVC-S/D showed an incremental diagnostic value combined with inferior vena cava size and collapsibility (P = .006). When a cutoff value of SVC-S/D < 1.9 was applied to the validation cohort, it showed acceptable accuracy of 72% and incremental diagnostic value combined with inferior vena cava parameters (P = .033). SVC-S/D from the subcostal window correlated better with RAP than that from the supraclavicular window (P < .001, Meng's test).
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: This publication was made possible by the Clinical and Translational Science Collaborative of Cleveland, Grant No. UL1TR000439 from the National Center for Advancing Translational Sciences of the National Institutes of Health, and the National Institutes of Health Roadmap for Medical Research. Mr Borowski was funded by an American Society of Echocardiography sonographers’ grant.

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Heart FailurePrecision of Echocardiographic Estimates of Right Atrial Pressure in Patients with Acute Decompensated Heart Failure

Background

Methods

Results

Conclusion

Section snippets

Study Population and Design

Patient Characteristics

Discussion

Conclusions

Acknowledgments

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am Heart J

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Mayo Clin Proc

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Heart Failure
Precision of Echocardiographic Estimates of Right Atrial Pressure in Patients with Acute Decompensated Heart Failure