Clinical Characteristics of Patients Undergoing Right Heart Catheterizations in Community Hospitals

Abstract

Background Recognition of precapillary pulmonary hypertension (PH) has significant implications for patient management. However, the low a priori chance to find this rare condition in community hospitals may create a barrier against performing a right heart catheterization (RHC). This could result in misclassification of PH and delayed diagnosis/treatment of precapillary PH. Therefore, we investigated patient characteristics and echocardiographic parameters associated with the decision whether to perform an RHC in patients with incident PH in 12 Dutch community hospitals. Methods and Results In total, 275 patients were included from the OPTICS (Optimizing PH Diagnostic Network in Community Hospitals) registry, a prospective cohort study with patients with incident PH; 157 patients were diagnosed with RHC (34 chronic thromboembolic PH, 38 pulmonary arterial hypertension, 81 postcapillary PH, 4 miscellaneous PH), while 118 patients were labeled as probable postcapillary PH without hemodynamic confirmation. Multivariable analysis showed that older age (>60 years), left ventricular diastolic dysfunction grade 2-3, left atrial dilatation were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension-associated conditions, right atrial dilatation, and tricuspid regurgitation velocity ≥3.7 m/s favor an RHC performance. Conclusions Older age and echocardiographic parameters of left heart disease were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension-associated conditions, right atrial dilation, and severe PH on echocardiography favored an RHC performance. As such, especially elderly patients may be at an increased risk of diagnostic delays and missed diagnoses of treatable precapillary PH, which could lead to a worse prognosis.

Keywords: diagnosis; elderly; pulmonary hypertension.

Figure 1. Flowchart representing patients’ numbers and study methods.

CTEPH indicates chronic thromboembolic pulmonary hypertension; PAH, pulmonary arterial hypertension; PH, pulmonary hypertension; and RHC, right heart catheterization.

Figure 2. Univariable predictors for right heart catheterization performance.

AF indicates atrial fibrillation; COPD, chronic obstructive pulmonary disease; LA, left atrial; LV, left ventricular; OR, odds ratio; NT‐proBNP, N‐terminal pro‐B‐type natriuretic peptide; RA, right atrial; RV, right ventricular; and TRV, tricuspid regurgitation velocity.

Figure 3. Independent predictors for the performance of right heart catheterization (RHC) in patients suspected of pulmonary hypertension.

A, Shows the number of patients with or without RHC according to the distribution of age. B, Shows the different stadia of diastolic dysfunction and within this group the number of RHC performance. C, The distribution of pulmonary arterial hypertension‐associated conditions (present or absent) as an independent predictor for RHC performance. D, Shows the number of patients with or without RHC performance according to the presence or absence of RA dilatation on echocardiography. E, Shows that patients suspected of pulmonary hypertension with a tricuspid regurgitation velocity ≥3.7 m/s have more RHC performed. F, Highlights that patients with a prior venous thromboembolic event received more RHCs. G, focusses on the distribution of prior VTE in patient with of without a RHC. PAH indicates pulmonary arterial hypertension; RA, right atrial; TR, tricuspid regurgitation; and VTE, venous thromboembolic events.

Figure 4. Arguments not to perform a right heart catheterization (RHC) by the health care provider.

PH indicates pulmonary hypertension.