超声心动图评估运动时肺动脉压的准确性：有创与无创同步比较
Accuracy of Echocardiography to Estimate Pulmonary Artery Pressures With Exercise: A Simultaneous Invasive-Noninvasive Comparison.
作者信息
van Riel Annelieke C M J, Opotowsky Alexander R, Santos Mário, Rivero Jose M, Dhimitri Andy, Mulder Barbara J M, Bouma Berto J, Landzberg Michael J, Waxman Aaron B, Systrom David M, Shah Amil M
机构信息
From the Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (A.C.M.J.v.R., B.J.M.M., B.J.B.); Netherlands Heart Institute, Utrecht (A.C.M.J.v.R., B.J.M.M.); Department of Cardiology, Boston Children's Hospital, and Harvard Medical School, MA (A.R.O., M.J.L.); Cardiovascular Medicine, Department of Medicine (A.R.O., J.M.R., A.D., M.J.L., A.M.S.) and Pulmonary and Critical Care Medicine, Department of Medicine, (A.B.W., D.M.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal (M.S.).
出版信息
Circ Cardiovasc Imaging. 2017 Apr;10(4). doi: 10.1161/CIRCIMAGING.116.005711.
BACKGROUND
Exercise echocardiography is often applied as a noninvasive strategy to screen for abnormal pulmonary hemodynamic response, but it is technically challenging, and limited data exist regarding its accuracy to estimate pulmonary arterial pressure during exercise.
METHODS AND RESULTS
Among 65 patients with exertional intolerance undergoing upright invasive exercise testing, tricuspid regurgitation (TR) Doppler estimates and invasive measurement of pulmonary arterial pressure at rest and peak exercise were simultaneously obtained. TR Doppler envelopes were assessed for quality. Correlation, Bland-Altman, and receiver-operating characteristic curve analyses were performed to evaluate agreement and diagnostic accuracy. Mean age was 62±13 years, and 31% were male. High-quality (grade A) TR Doppler was present in 68% at rest and 34% at peak exercise. For grade A TR signals, echocardiographic measures of systolic pulmonary arterial pressure correlated reasonably well with invasive measurement at rest (=0.72, <0.001; bias, -2.9±8.0 mm Hg) and peak exercise (=0.75, <0.001; bias, -1.9±15.6 mm Hg). Lower quality TR signals (grade B and C) correlated poorly with invasive measurements overall. In patients with grade A TR signals, mean pulmonary arterial pressure-to-workload ratio at a threshold of 1.4 mm Hg/10 W was able to identify abnormal pulmonary hemodynamic response during exercise (>3.0 mm Hg/L per minute increase), with 91% sensitivity and 82% specificity (area under the curve, 0.90; 95% confidence interval, 0.77-1.0; =0.001).
CONCLUSIONS
Agreement between echocardiographic and invasive measures of pulmonary pressures during upright exercise is good among the subset of patients with high-quality TR Doppler signal. While the limits of agreement are broad, our results suggest that in those patients, sensitivity is adequate to screen for abnormal pulmonary hemodynamic response during exercise.
背景
运动超声心动图常被用作一种无创策略来筛查异常的肺血流动力学反应，但该技术具有挑战性，且关于其在运动期间估计肺动脉压准确性的数据有限。
方法与结果
在65例有运动不耐受的患者中进行直立有创运动试验，同时获得三尖瓣反流（TR）多普勒估计值以及静息和运动峰值时的肺动脉压有创测量值。评估TR多普勒包络的质量。进行相关性分析、布兰德-奥特曼分析和受试者操作特征曲线分析以评估一致性和诊断准确性。平均年龄为62±13岁，31%为男性。静息时68%的患者存在高质量（A级）TR多普勒，运动峰值时为34%。对于A级TR信号，静息时收缩期肺动脉压的超声心动图测量值与有创测量值相关性良好（r = 0.72，P < 0.001；偏差，-2.9±8.0 mmHg），运动峰值时相关性也良好（r = 0.75，P < 0.001；偏差，-1.9±15.6 mmHg）。总体而言，较低质量的TR信号（B级和C级）与有创测量值相关性较差。在有A级TR信号的患者中，在阈值为1.4 mmHg/10 W时平均肺动脉压与工作量之比能够识别运动期间异常的肺血流动力学反应（每分钟增加>3.0 mmHg/L），敏感性为91%，特异性为82%（曲线下面积，0.90；95%置信区间，0.77 - 1.0；P = 0.001）。
结论
在具有高质量TR多普勒信号的患者亚组中，直立运动期间肺动脉压的超声心动图测量值与有创测量值之间的一致性良好。虽然一致性界限较宽，但我们的结果表明，对于这些患者，敏感性足以筛查运动期间异常的肺血流动力学反应。
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