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Systolic pulmonary artery pressure assessed during routine exercise Doppler echocardiography: insights of a real-world setting in patients with elevated pulmonary pressures

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Pulmonary hypertension is a marker of disease severity. Exercise Doppler echocardiography (EDE) has proven to be feasible and reliable to assess pulmonary pressure. Increase in systolic pulmonary artery pressure (sPAP) has diagnostic and prognostic value in controlled studies. However, its value when assessed during routine examination in patients with cardiopulmonary diseases and resting sPAP > 35 mmHg is not clearly defined. Clinical documentation and offline reevaluation of digitally stored EDE examinations of patients with appropriate clinical indications for EDE were analyzed. N = 278 patients with sPAP at rest > 35 mmHg met inclusion criteria. One patient was lost to follow-up. Mean age of patients was 72 ± 10 years, 178 (64%) of the study population were men. There were no relevant differences among survivors and non-survivors concerning comorbidities. Exercise performance (3.6 ± 1.2 vs. 4.9 ± 1.4 MET, p < 0.001) was lower, whereas sPAP during exercise was higher (67.3 ± 14.7 vs. 62.1 ± 13.2 mmHg, p = 0.027) in non-survivors. Univariate predictors of all-cause mortality were NYHA functional class III (HR = 2.56, p < 0.001), ≥ 2-vessels coronary artery disease (CAD) (HR = 1.93, p = 0.04), left atrial diameter > 45 mm (HR = 2.58, p < 0.001), rest sPAP > 42 mmHg (HR = 1.94, p = 0.010) and ΔsPAP increase ≥ 0.23 mmHg/Watt (HF = 1.92, p = 0.010). After multivariate analysis, NYHA functional class III (HR = 2.35, p < 0.001), LA diameter (HR = 2.28, p = 0.003) and sPAP increase ≥ 0.23 mmHg/Watt (HF = 2.19, p = 0.002) remained significant predictors of mortality, whereas a double product (HR = 0.42, p = 0.005) was associated with better prognosis. sPAP assessment during routine EDE provides relevant prognostic information comparable to findings in studies in selected populations. A higher sPAP increase at lower exercise performance shows significant association with increased of mortality.

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Body mass index


Coronary artery disease


Double product


Exercise Doppler echocardiography


Ejection fraction


Heart failure with reduced ejection fraction


Heart failure with mid-range ejection fraction


Heart failure with preserved ejection fraction


Left atrium


Left ventricle


Metabolic equivalent of task


New York Heart Association functional class


Pulmonary arterial hypertension


Pulmonary hypertension


Right atrial pressure


Right ventricular peak systolic pressure gradient


Systolic pulmonary artery pressure

sPAP Max:

sPAP at peak exercise


Relative sPAP change at rest vs. exercise


World Health Organization


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Correspondence to Derliz Mereles.

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The authors declare that they have no conflict of interest.

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All procedures were in accordance with the ethical standards of the Ethics Committee of the University of Heidelberg and in concordance with the 1964 Helsinki declaration and its later amendments.

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Informed consent was obtained from all individual participants included in the study.

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Susanne Korff and Patricia Enders-Gier have contributed equally to this work.

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Korff, S., Enders-Gier, P., Uhlmann, L. et al. Systolic pulmonary artery pressure assessed during routine exercise Doppler echocardiography: insights of a real-world setting in patients with elevated pulmonary pressures. Int J Cardiovasc Imaging 34, 1215–1225 (2018).

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