Systolic Pulmonary Artery Pressure Thresholds Predictive of Dyspnea on Stress Doppler Echocardiography in Mitral Stenosis

Saléha Lehachi; Fadila Daimellah; Saida Khelil; Zakia Bennoui; Djohar Hannoun; Youcef Laid; Rachid Mechmeche; Mohand Said Issad

doi:10.37616/2212-5043.1354

Systolic Pulmonary Artery Pressure Thresholds Predictive of Dyspnea on Stress Doppler Echocardiography in Mitral Stenosis

J Saudi Heart Assoc. 2024 Jan 8;35(4):354-362. doi: 10.37616/2212-5043.1354. eCollection 2023.

Authors

Saléha Lehachi¹, Fadila Daimellah¹, Saida Khelil¹, Zakia Bennoui¹, Djohar Hannoun², Youcef Laid², Rachid Mechmeche³, Mohand Said Issad¹

Affiliations

¹ Cardiology Department University Hospital Center Beni Messous, Algiers, Algeria.
² National Institute of Statistics, Algiers, Algeria.
³ Cardiology Department at Rabta Hospital, Tunis, Tunisia.

Abstract

Background: On Stress Doppler Echocardiography (SDE) in mitral stenosis, the systolic pulmonary artery pressure (SPAP) threshold at peak exercise recommended by the guidelines as an indication for percutaneous mitral commissurotomy (PMC) used to be 60 mmHg. However, because of the paucity of studies, that threshold has been controversial. The Europeans stopped using the value in 2007, followed by the Americans in 2014.

Objective: Determine SPAP thresholds on SDE at peak exercise and post-exercise predictive of dyspnea as an indication for PMC in mitral stenosis.

Method and results: Three hundred mitral stenosis patients with a mitral valve area (MVA) ≤ 2 cm² and NYHA I-II-III were included. A treadmill stress test (Bruce protocol) was used in all cases to distinguish dyspneic patients (n = 182) from non dyspneic patients (n = 118). SDE was performed on a stress echocardiography bed, starting at 30 W and increasing by 30 W every 3 min. At peak exercise, the best SPAP threshold obtained was 75 mmHg: specificity (Sp) = 0.98 (0.94-1), positive likelihood ratio (LR+) = 47 (41-50), positive predictive value (PPV) = 0.99 (0.95-1), and positive predictive error (PPE) = 0.01 (0.002-0.05). This compared with, respectively, 0.34, 1, 0.69 and 0.31 at 60 mmHg. Post-exercise, the best SPAP threshold found was 60 mmHg: Sp = .94 (0.88-0.97), LR = 9 (4-10), PPV = 0.94 (0.87-0.97), and PPE = 0.06 (0.03-0.13).

Conclusion: Regarding the prediction of dyspnea as an indication for PMC, our study shows that a SPAP value at peak exercise of 60 mmHg lacks predictive power (LR+=1). The optimal threshold observed was 75 mmHg at peak exercise (LR+ = 47 [41-50]) and 60 mmHg post-exercise (LR+ = 9 [4-10]).

Keywords: Exercise testing; Mean systolic pulmonary pressure; Mitral stenosis; Stress echocardiography.