, 2025-04-21 11:48:00
To assess how a patient with pulmonary arterial hypertension (PAH) is faring on therapy, look at the right heart, said Anjali Vaidya, MD, in a presentation at the Annual Meeting of the American College of Cardiology.
When it comes to right heart performance, “the echo doesn’t lie,” said Vaidya, a professor of medicine and co-director of the Advanced Pulmonary Hypertension Program at Temple University Lewis Katz School of Medicine, Philadelphia.
Vaidya offered several tools and tips for optimal management of PAH.
Look at right heart performance to assess how a patient is doing on therapy, Vaidya said. She cited a 2017 study showing that differences in right ventricular (RV) morphology, rather than function, could be indicators of increased afterload in patients with pulmonary hypertension (PH) and normal left ventricular function. Additionally, multiple high-risk echocardiographic features representing RV function, tricuspid valve regurgitation, and estimation of right atrial pressure have been shown to predict mortality in PAH, as published in the European Respiratory Journal and American Heart Journal.
Guidelines published in 2022 by the European Society of Cardiology and European Respiratory Society also emphasized the value of various right heart parameters, Vaidya said.
The guidelines included clinical right heart failure, biomarkers such as brain natriuretic peptide (BNP) or N-terminal prohormone of BNP, right atrial area, RV function, and cardiac output as indicators of low, medium, and high risk, respectively, of estimated 1-year mortality in patients with PAH.
Tricuspid Annular Plane Systolic Excursion (TAPSE) is another measure of RV function and risk in PAH, Vaidya said in her presentation. In a recent study published in Circulation: Heart Failure, researchers found that dividing TAPSE by RV area provided added value in predicting adverse cardiovascular outcomes.
Guidelines published in 2025 by the American Society of Echocardiography for echocardiographic assessment of the right heart in adults with PAH include novel techniques such as three-dimensional (3D) images to show RV volume and assessment of right atrial function across the cardiac cycle, said Vaidya.
Virtual Tool Offers Alternative
Although 3D imaging is referenced in current guidelines, a new virtual echocardiography screening tool (VEST) developed by Vaidya and colleagues offers broadly accessible PAH screening that is less reliant on advanced expertise in cardiology or echocardiography.
In an initial study published in 2020, VEST was 80% sensitive and 76% specific in predicting PAH hemodynamics. The VEST score is based on three routine echocardiographic metrics: Left atrial size, transmitral E:e’ ratio (using tissue Doppler), and the presence or absence of interventricular systolic septal flattening, Vaidya said.
In a 2023 study published in The American Journal of Cardiology, Vaidya and colleagues applied the VEST algorithm to echocardiographic reports several months prior to evaluation at a PAH referral center. They found that more than 90% of patients with PAH had ECG reports with positive VEST scores.
In the most recent research on VEST, published online in the American Heart Journal, Vaidya and colleagues developed an algorithm based on electronic medical record data that was 100% accurate in calculating VEST scores. A score of +3 identified patients at highest risk for PH and for referral to a PH center. The study population included 554 adults who underwent transthoracic ECG with elevated pulmonary pressure estimation. Of the highest risk patients, nearly one third had not been clinically recognized and referred to an accredited center for PH care, Vaidya noted. “Of those who had been evaluated in an accredited PH center, 95% had undergone the gold standard of testing compared to only 37% of those who had not,” she said in the presentation.
Takeaways and Next Steps
VEST can potentially change practice by helping physicians who do not have training and expertise in advanced echocardiography interpretation to recognize patients at high risk for PAH much easier and earlier, Vaidya said in an interview.
“We are studying this with implementation across more health centers for broader applicability to help identify patients who would benefit from expedited PH expertise,” she told Medscape Medical News. More research is needed, but the results support VEST as an accessible and accurate tool for earlier diagnosis and referrals to improve patient outcomes, Vaidya said.
Clinical Considerations
Echocardiography is an excellent screening tool for PH, as it is noninvasive and well-tolerated and carries minimal risk, with no radiation, said Nicholas Hill, MD, a pulmonologist at Tufts Medicine, Boston, in an interview.
Echocardiology provides very useful data in evaluating and monitoring patients with PH, said Hill. “However, there are challenges related to the complex morphology of the RV, patient factors such as obesity or parenchymal lung disease, variability in technical skills of those performing echoes, and interobserver variability between readers,” he said.
“Estimation of RV systolic pressure has inherent inaccuracies and may either over- or underestimate measurements made at right heart catheterization,” he said. “Early detection may be challenging because the right side of the heart may be subtle and hard to detect unless the disease is more advanced,” he added.
The VEST screening tool is based on three routine measurements that are likely to detect fairly early changes, Hill told Medscape Medical News. “It has the potential to facilitate early detection, and it also helps to differentiate noninvasively between groups 1 and 2 PH,” he said.
Although VEST seems to perform well at enhancing detection of PH at a single center, studies at other institutions to test generalizability are important, said Hill. Other potential research might address whether the measurements used in VEST are the best echo measurements for detecting PH and whether combination with other simple non-echo assessments might be assessed, he added.
Vaidya had no financial conflicts to disclose. Hill had no financial conflicts to disclose.
