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The age of the patient should be taken into account when interpreting Doppler assessed pulmonary artery pressures
The Age of the Patient Should Be Taken into Account when Interpreting Doppler Assessed Pulmonary Artery Pressures Jean-Claude Dib, MD, Eric Abergel, MD, Catherine Rovani, MD, Hanna Raffoul, MD, and Benoit Diebold, MD, PhD, Paris, France
The impact of aging on the systolic artery pressure (SPAP) value is not well known. We selected 134 echocardiographic Doppler examinations considered as normal (presence of a sinus rhythm, absence of chronic obstructive pulmonary disease or pulmonary embolism, normal global or segmental wall motion, no right or left ventricular hypertrophy or dilatation, no signif-
sure the SPAP with the simplified Bernoulli equation. There was a highly significant (p = 0 . 0 0 0 1 ) correlation (r = 0 . 4 7 ) between SPAP values and the age o f the patient. SPAP increased progressively with age from 23 - 5 m m H g between 2 0 to 2 9 years old to 32 -+ 6 nun H g w h e n 8 0 years old or more. The interpretation o f the SPAP should take into account the age. (J Am Soc
icant valvular disease, no pericarditis), with a clearly measurable tricuspid insufficiency allowing us to mea-
Echocardiogr 1997;10:72-3.)
T h e assessment o f the pulmonary artery pressure using Doppler echocardiography is now widely accepted and routinely used. Values for the systolic artery pressure (SPAP) can be obtained with Doppler imaging using the peak velocity o f the tricuspid insufficiency and the simplified Bernoulli equation (DP = 4V2). 1 The interpretation o f these values remains a source o f problems because the possible relationship between the age o f the patient and the SPAP value has not yet been studied in healthy subjects. The current study was designed to answer this question.
normal right cavities and absence o f pericardial disease; and 5) normal left ventricular geometry and function with normal segmental function and normal dimensions. The following criteria were used to determine whether an examination result was normal (measured on a left parasternal long axis view): left ventricular end-diastolic diameter was 54 mm or less; the shortening fraction was 27 or greater; the interventricular septum and left posterior wall thicknesses were 12 mm or less; and the left atrial diameter was less than 40 mm.
RESULTS METHODS
We reviewed our echocardiographic database (12,737 reports, recorded prospectively between March 1990 and December 1994) to select echocardiographic examinations with clearly measurable tricuspid insufficiency. This allowed us to measure the SPAP values. All the other measures were considered to be normal. Normality was defined as follows: 1) presence o f a sinus rhythm; 2) absence o f chronic obstructive pulmonary disease or pulmonary embolism; 3) absence or minimal valvular regurgitation; 4) From the Department of Cardiology, Broussais Hospital, Paris, France. Reprint requests: J-C. Dib, MD, Department of Cardiology, Broussais Hospital, 96 rue Didot, 75014, Paris, France. Copyright 9 1997 by the AmericanSocietyof Echocardiography. 0894-7317/97 $5.00+0 27/1/75422 72
The study comprised 134 examinations performed in patients aged 20 to 85 years. All the patients had been seen in an outpatient clinic by a senior cardiologist, and the echo Doppler examinations were done for the following conditions: hypertcnsion (n = 37); murmur observed at the physical examination ( n = 30); suspected coronary artery disease (n = 20); electrocardiogram abnormality, such as a left bundle branch block, right bundle branch block, or Wolf-Parkinson-White syndrome, (n = 20); suspected pericarditis (n = 10); and for other reasons (n = 17). The mean main dimensions obtained for all the patients were as follows: left ventricular end-diastolic diameter = 47 + 4.7 mm; interventricular septum = 9.3 + 1.6 mm; left posterior wall thickness 8.4 + 1.5 mm; and left atrial diameter = 33.7 + 5.2 mm. A highly significant
Journal of the American Society of Echocardiography Volume 10 Number 1
Table 1
D i b et al.
73
Mean SPAP values for subgroups according to age Age (yrs)
n SPAP p value Range of SPAP values
20-29
30-39
40-49
19 23 _+ 5
24 24 • 5
19 24 + 3
NS 16-29
NS 18-32
28 26• NS
18- 32
60-69
50-59
23 30• <0.003
20-40
70-79
16 30• NS
22-43
>80
5 32 • NS
20-38
22-36
SPAP,systolicarterypressure.
( p = 0 . 0 0 0 1 ) correlation ( r = 0.47) was f o u n d between the SPAP values and the age o f the patient. N o n e o f the other parameters (left ventricular end-diastolic diameter, interventricular septum, left posterior wall thickness, left atrial diameter, indication for the echo D o p p l e r examination) was significantly associated with the SPAP values in univariate and multivariate analyses. T h e subgroups were defined according to age, and the m e a n values o f the SPAP are presented in Table 1. Thus our results s h o w e d a clear relationship between the SPAP value and age. A significant increase was f o u n d in the SPAP value for patients older than 60 years. Some limitations o f the study are as follows: 1) this was a retrospective analysis o f prospectively acquired data; 2) some very minimal abnormalities were reported as being normal because the mean dimensions were clearly within the normal range, and m o s t o f the clinically suspected pathologic conditions were n o t confirmed in the 134 patients by the echo D o p p l e r examination (normal global and segmental left contractile function, no organic or minimal valvular disease, n o pericarditis). T h e incidence o f hypertension, which was n o t e d in 37 patients, was similar in the different age groups; and 3) n o invasive measurements o f the SPAP values were collected o n the study population. D o p p l e r estimation o f the SPAP value has been s h o w n to correlate strongly with the invasive measurement o f the latter. 2 The fixed value chosen for the right atrial pressure (10 m m H g ) is widely accepted 3 but is certainly t o o high. Because it was
recorded for all the patients, it had no influence o n the correlations and on the final conclusion o f this work. We believe that the rise in the SPAP values in older patients was the result o f an increase in the p u l m o n a r y vascular resistance, a decrease in the cardiac output, and an increase in systolic b l o o d pressure. This finding also was observed in an invasive h e m o d y n a m i c study in a predominantly hypertensive population. 4 These data show that in a population with very minimal echocardiographic abnormalities, a clear relationship exists between the age o f the patient and the SPAP value. T h e interpretation o f SPAP values should take age into a c c o u n t in patients older than 60 years. Consideration should be given to age-related changes in the p u l m o n a r y circulation when defining physiologically normal values.
REFERENCES
1. YockPG, Popp RL. Noninvasiveestimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation. Circulation 1984;70:657-62. 2. Berger M, Haimowitz A, Van Tosh A, BerdoffRL, Goldberg E. Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound. J Am Coil Cardio11985;6:359-65. 3. Currie PJ, Hagler DI, Seward JB, et al. Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler -catheterization study in 127 patients, l Am Coil Cardiol 1985;6:750-6. 4. Ghali JK, Liao Y, Cooper RS, Cao G. Changes in pulmonary hemodynamics with aging in a predominantly hypertensive population. Am J Cardio11992;70:367-70.
The impact of aging on the systolic artery pressure (SPAP) value is not well known. We selected 134 echocardiographic Doppler examinations considered as normal (presence of a sinus rhythm, absence of chronic obstructive pulmonary disease or pulmonary embolism, normal global or segmental wall motion, no right or left ventricular hypertrophy or dilatation, no signif-
sure the SPAP with the simplified Bernoulli equation. There was a highly significant (p = 0 . 0 0 0 1 ) correlation (r = 0 . 4 7 ) between SPAP values and the age o f the patient. SPAP increased progressively with age from 23 - 5 m m H g between 2 0 to 2 9 years old to 32 -+ 6 nun H g w h e n 8 0 years old or more. The interpretation o f the SPAP should take into account the age. (J Am Soc
icant valvular disease, no pericarditis), with a clearly measurable tricuspid insufficiency allowing us to mea-
Echocardiogr 1997;10:72-3.)
T h e assessment o f the pulmonary artery pressure using Doppler echocardiography is now widely accepted and routinely used. Values for the systolic artery pressure (SPAP) can be obtained with Doppler imaging using the peak velocity o f the tricuspid insufficiency and the simplified Bernoulli equation (DP = 4V2). 1 The interpretation o f these values remains a source o f problems because the possible relationship between the age o f the patient and the SPAP value has not yet been studied in healthy subjects. The current study was designed to answer this question.
normal right cavities and absence o f pericardial disease; and 5) normal left ventricular geometry and function with normal segmental function and normal dimensions. The following criteria were used to determine whether an examination result was normal (measured on a left parasternal long axis view): left ventricular end-diastolic diameter was 54 mm or less; the shortening fraction was 27 or greater; the interventricular septum and left posterior wall thicknesses were 12 mm or less; and the left atrial diameter was less than 40 mm.
RESULTS METHODS
We reviewed our echocardiographic database (12,737 reports, recorded prospectively between March 1990 and December 1994) to select echocardiographic examinations with clearly measurable tricuspid insufficiency. This allowed us to measure the SPAP values. All the other measures were considered to be normal. Normality was defined as follows: 1) presence o f a sinus rhythm; 2) absence o f chronic obstructive pulmonary disease or pulmonary embolism; 3) absence or minimal valvular regurgitation; 4) From the Department of Cardiology, Broussais Hospital, Paris, France. Reprint requests: J-C. Dib, MD, Department of Cardiology, Broussais Hospital, 96 rue Didot, 75014, Paris, France. Copyright 9 1997 by the AmericanSocietyof Echocardiography. 0894-7317/97 $5.00+0 27/1/75422 72
The study comprised 134 examinations performed in patients aged 20 to 85 years. All the patients had been seen in an outpatient clinic by a senior cardiologist, and the echo Doppler examinations were done for the following conditions: hypertcnsion (n = 37); murmur observed at the physical examination ( n = 30); suspected coronary artery disease (n = 20); electrocardiogram abnormality, such as a left bundle branch block, right bundle branch block, or Wolf-Parkinson-White syndrome, (n = 20); suspected pericarditis (n = 10); and for other reasons (n = 17). The mean main dimensions obtained for all the patients were as follows: left ventricular end-diastolic diameter = 47 + 4.7 mm; interventricular septum = 9.3 + 1.6 mm; left posterior wall thickness 8.4 + 1.5 mm; and left atrial diameter = 33.7 + 5.2 mm. A highly significant
Journal of the American Society of Echocardiography Volume 10 Number 1
Table 1
D i b et al.
73
Mean SPAP values for subgroups according to age Age (yrs)
n SPAP p value Range of SPAP values
20-29
30-39
40-49
19 23 _+ 5
24 24 • 5
19 24 + 3
NS 16-29
NS 18-32
28 26• NS
18- 32
60-69
50-59
23 30• <0.003
20-40
70-79
16 30• NS
22-43
>80
5 32 • NS
20-38
22-36
SPAP,systolicarterypressure.
( p = 0 . 0 0 0 1 ) correlation ( r = 0.47) was f o u n d between the SPAP values and the age o f the patient. N o n e o f the other parameters (left ventricular end-diastolic diameter, interventricular septum, left posterior wall thickness, left atrial diameter, indication for the echo D o p p l e r examination) was significantly associated with the SPAP values in univariate and multivariate analyses. T h e subgroups were defined according to age, and the m e a n values o f the SPAP are presented in Table 1. Thus our results s h o w e d a clear relationship between the SPAP value and age. A significant increase was f o u n d in the SPAP value for patients older than 60 years. Some limitations o f the study are as follows: 1) this was a retrospective analysis o f prospectively acquired data; 2) some very minimal abnormalities were reported as being normal because the mean dimensions were clearly within the normal range, and m o s t o f the clinically suspected pathologic conditions were n o t confirmed in the 134 patients by the echo D o p p l e r examination (normal global and segmental left contractile function, no organic or minimal valvular disease, n o pericarditis). T h e incidence o f hypertension, which was n o t e d in 37 patients, was similar in the different age groups; and 3) n o invasive measurements o f the SPAP values were collected o n the study population. D o p p l e r estimation o f the SPAP value has been s h o w n to correlate strongly with the invasive measurement o f the latter. 2 The fixed value chosen for the right atrial pressure (10 m m H g ) is widely accepted 3 but is certainly t o o high. Because it was
recorded for all the patients, it had no influence o n the correlations and on the final conclusion o f this work. We believe that the rise in the SPAP values in older patients was the result o f an increase in the p u l m o n a r y vascular resistance, a decrease in the cardiac output, and an increase in systolic b l o o d pressure. This finding also was observed in an invasive h e m o d y n a m i c study in a predominantly hypertensive population. 4 These data show that in a population with very minimal echocardiographic abnormalities, a clear relationship exists between the age o f the patient and the SPAP value. T h e interpretation o f SPAP values should take age into a c c o u n t in patients older than 60 years. Consideration should be given to age-related changes in the p u l m o n a r y circulation when defining physiologically normal values.
REFERENCES
1. YockPG, Popp RL. Noninvasiveestimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation. Circulation 1984;70:657-62. 2. Berger M, Haimowitz A, Van Tosh A, BerdoffRL, Goldberg E. Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound. J Am Coil Cardio11985;6:359-65. 3. Currie PJ, Hagler DI, Seward JB, et al. Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler -catheterization study in 127 patients, l Am Coil Cardiol 1985;6:750-6. 4. Ghali JK, Liao Y, Cooper RS, Cao G. Changes in pulmonary hemodynamics with aging in a predominantly hypertensive population. Am J Cardio11992;70:367-70.