2022 ESC/ERS 2022 guidelines for the diagnosis and treatment of pulmonary hypertension – the impact on clinical practice

Published 29/09/2023

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As a cardiac physiologist, I work in various settings, from community diagnostic hubs to tertiary centres, and collaborate with clinicians who have varying levels of familiarity with pulmonary hypertension (PH). Therefore, it is important that my echocardiogram reports are accurate and informative to help clinicians to make the right diagnostic and management decisions. I always try to align my examinations and reports to the 2022 ESC/ERS diagnostic algorithm, developed to aid the early detection of PH.

When dealing with breathless patients, it’s crucial to provide the triaging team with as much information as possible. It's important to consider:

  1. Measuring conducting brain natriuretic peptide (BNP)/N-terminal prohormone of brain natriuretic peptide (NTpro-BNP) concentrations
  2. Clinical examinations to check for signs of heart failure and syncope
  3. Monitoring symptom progression

One of the main updates in the 2022 ESC/ERS guidelines was the introduction of the simplified, four-strata risk assessment tool to stratify patients with PH at follow-up by risk level. The four-strata risk assessment model is based upon World Health Organization Functional Class, 6-minute walk distance and BNP/NT-proBNP concentrations with additional variables considered as necessary.1

Echocardiography (echo) is recommended as the first-line, non-invasive, diagnostic investigation in suspected PH and as a follow-up tool when tricuspid regurgitation velocity (TRV) is abnormal (in the presence of other markers of PH).1  

Routine echo measurements/data can be used to assess the probability of PH. ESC/ERS guidelines recommend assigning an echocardiographic probability of PH, based on an abnormal TRV and the presence of other echocardiographic signs.1 Professionally, I have found that using the recommended data outlined in the guidelines can provide better reports for clinicians. This is particularly important when there are notable changes between echo exams such as changes in right ventricle size or function, increased TRV, or the presence of pericardial effusion.

In my practical experience, I have found that following the guidelines proves to be helpful for patients with an intermediate probability of PH on echo. However, it is important to interpret supportive measurements, such as pulmonary artery acceleration or mid-systolic notching, in the context of the underlying cause.

Patients with adult congenital heart disease (ACHD) undergo regular echocardiographic monitoring and prompt action is taken, when necessary, at tertiary centres if PH is suspected. I am excited to attend the Janssen-sponsored symposium ‘Echo PH screening 1 year on from ESC/ERS 2022 guidelines: How has practice changed in adult congenital heart disease (ACHD)?’ at BSEcho 2023. Professors Robin Condliffe and Kostas Dimopoulos will discuss the optimal clinical approaches to echocardiographic screening for PH in patients with ACHD. I look forward to seeing you there!

UK healthcare professionals can visit the Act on PAH website for more information on PH and to access additional educational resources.

Ivo Ferreira de Andrade
Highly specialised cardiac physiologist and Education Lead for adult echocardiography, Manchester University NHS Foundation Trust, UK

  1. Humbert M, et al. Eur Heart J. 2022;43:3618–731.

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CP-405015 | September 2023