Simple algorithm to narrow down the candidates to receive echocardiography in patients with chronic liver disease for suspected pulmonary hypertension

• Published in: JGH open 2022-11, Vol.6 (11), p.774-781
• Main Authors: Yamashita, Koji, Kurosaki, Masayuki, Nakanishi, Hiroyuki, Tanaka, Yuki, Ishido, Shun, Inada, Kento, Kirino, Sakura, Hayakawa, Yuka, Matsumoto, Hiroaki, Nobusawa, Tsubasa, Kakegawa, Tatsuya, Higuchi, Mayu, Takaura, Kenta, Tanaka, Shohei, Maeyashiki, Chiaki, Kaneko, Shun, Tamaki, Nobuharu, Yasui, Yutaka, Tsuchiya, Kaoru, Takahashi, Yuka, Miyazaki, Ryoichi, Ashikaga, Takashi, Enomoto, Nobuyuki, Izumi, Namiki
• Format: Article
• Language: English
• Subjects: Anemia; Ascites; Cardiac catheterization; Cardiovascular disease; Clinical medicine; Esophagus; Heart failure; Hemoglobin; Hepatitis B; Hepatitis C; hepatology; Intubation; Liver diseases; Normal distribution; Original; Patients; Peptides; portal hypertension; Pulmonary arteries; Pulmonary hypertension; screening and diagnosis; Thrombosis
• ISSN: 2397-9070; 2397-9070
• DOI: 10.1002/jgh3.12821

Aims Portopulmonary hypertension (PoPH) is a subtype of pulmonary arterial hypertension related to portal hypertension. The definitive diagnosis of PoPH is made by invasive right heart catheterization. Alternatively, pulmonary arterial hypertension may be recognized noninvasively from the tricuspid regurgitant pressure gradient (TRPG), measured by echocardiography. In this study, we aimed to establish a simple algorithm to identify chronic liver disease patients with a high TRPG value in order to narrow down the candidates to receive echocardiography. Methods and Results TRPG was measured by echocardiography in 152 patients with chronic liver disease. Factors predictive of TRPG >30 mmHg were investigated. There were 28 (18%) cases with TRPG >30 mmHg. Independent factors associated with a high TRPG were the presence of shortness of breath, high serum brain natriuretic peptide (BNP), and low serum albumin. Child–Pugh class or the presence of ascites, varices, or encephalopathy was not associated with TRPG. There was a correlation between the serum BNP and TRPG, and the optimal cutoff value of BNP by the Youden index was 122 pg/mL, and by 100% sensitivity was 50 pg/mL. A combination of these factors identified patients with a high probability of TRPG >30 mmHg (n = 12, positive predictive value [PPV] of 83%), no probability (n = 80, PPV 0%), and intermediate probability (n = 60, PPV 25–34%). This algorithm has reduced the number of patients needing echocardiography by 53%. Conclusions A simple algorithm using the presence of shortness of breath, serum BNP, and albumin levels can narrow down the candidates to receive echocardiography. Portopulmonary hypertension is a complication with poor prognosis in patients with cirrhosis, but it is difficult to detect early because of the lack of early symptoms. In clinical practice, it is not realistic to perform invasive right heart catheterization, or even echocardiography, in all patients with chronic liver disease, limiting the wide range of screening. A simple algorithm using the presence of shortness of breath, serum BNP and albumin levels can narrow down of the candidates to receive echocardiography for suspected pulmonary hypertension.