Echocardiographic Signs of Pulmonary Hypertension (PH)

1. Elevated Pulmonary Artery Systolic Pressure (PASP)

Most important screening parameter.

Estimated from TR Jet Velocity:

PASP = 4(V_{TR})^2 + RAP

TR velocity >2.8–3.4 m/s suggests PH

Higher velocity → higher probability of PH

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2. Right Ventricular (RV) Changes

RV dilatation

RV hypertrophy (RV free wall >5 mm)

Reduced RV systolic function

RV pressure overload pattern

Severe PH:

RV larger than LV

Reduced TAPSE

Reduced RV FAC

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3. Interventricular Septal Flattening

Due to RV pressure overload.

D-shaped LV in PSAX

Systolic flattening → pressure overload

Diastolic flattening → volume overload

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4. Right Atrial Enlargement

Enlarged RA area

Dilated IVC with reduced collapse

Suggests elevated right-sided pressures.

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5. Pulmonary Artery Abnormalities

Dilated main pulmonary artery

PA diameter >25 mm

Early systolic notching on RVOT Doppler

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6. Shortened Pulmonary Acceleration Time (PAT)

RVOT PW Doppler:

PAT <105 ms suggests PH

Mid-systolic notching may be present

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7. Increased Right Atrial Pressure (RAP)

IVC findings:

Dilated IVC (>2.1 cm)

Poor inspiratory collapse (<50%)

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8. Secondary TR / PR

Functional tricuspid regurgitation

Pulmonary regurgitation may increase with severe PH

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9. Reduced LV Size

Due to RV pressure overload and septal shift.

Small underfilled LV may be seen in advanced PH.

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Echo Probability of PH (ESC/ERS Concept)

Low Probability

TR velocity ≤2.8 m/s

No additional PH signs

Intermediate Probability

TR velocity 2.9–3.4 m/s with other PH signs

High Probability

TR velocity >3.4 m/s OR

TR velocity 2.9–3.4 m/s + multiple supportive signs

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Important Supportive Echo Findings

RV enlargement

RA enlargement

D-shaped LV

Dilated PA

Short PAT

Dilated IVC

RV dysfunction

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Gold Standard

Echo suggests probability only.

Definitive diagnosis:

Right heart catheterization (RHC).

Comments

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𝘼𝙣𝙩𝙞𝙘𝙤𝙖𝙜𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝘼𝙛𝙩𝙚𝙧 𝙎𝙩𝙧𝙤𝙠𝙚 in Patient with AF and acute IS/TIA European Heart Association Guideline recommends: • 1 days after TIA • 3 days after mild stroke • 6 days after moderate stroke • 12 days after severe stroke Early anticoagulation can decrease a risk of recurrent stroke and embolic events but may increase a risk of secondary hemorrhagic transformation of brain infarcts. The 1-3-6-12-day rule is a known consensus with graded increase in delay of anticoagulation between 1 and 12 days after onset of ischemic stroke or transient ischemic attack(TIA), according to neurological severity based on European expert opinions. However, this rule might be somewhat later than currently used in a real-world practical setting.

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