Exercise-Induced Pulmonary Hypertension or Not? Comparison of Current and Previous Diagnostic Criteria

Document Type

Conference Proceeding

Publication Date

5-2026

Publication Title

American Journal of Respiratory and Critical Care Medcine

Abstract

Introduction: Exercise-induced pulmonary hypertension (EiPH) is currently described by a mean pulmonary artery pressure/cardiac output (mPAP/CO) slope of 3 mmHg/L/min between rest and exercise. Prior recommendations used mPAP above 30 mmHg during invasive exercise hemodynamics OR tricuspid regurgitation velocity (TRV) exceeding 3.4 m/s during exercise echocardiography as the primary diagnostic thresholds. Case description: A 59-year-old woman with a past medical history significant for systemic lupus erythematosus established care with the pulmonology office for dyspnea on exertion that started insidiously two years ago. Her exercise capacity gradually declined from running marathons to being able only to go up one flight of stairs. Further workup showed unremarkable pulmonary function test with FEV1/ FVC ratio of 84%, FEV1 70% and FVC 65%, DLCO of 77% of predicted. Echocardiogram showed ejection fraction of 60%, right ventricular systolic pressure (RVSP) 20-25 mmHg, mild mitral regurgitation (MR) with mild myxomatous degeneration, and E/E ’ medial and lateral ratios of 10.5 and 9.0, respectively. Computed tomography of the thorax without intravenous contrast was unremarkable. On Cardiopulmonary exercise test (CPET), the patient reached 49% of the peak oxygen uptake (VO2 max), early anerobic threshold at 30% of the predicted peak VO2, and appropriate ventilatory reserve with no evidence of hypoxemia at maximal exercise — suggesting circulatory impairment. The CT angiogram showed no coronary artery obstruction. Bicycle stress echocardiogram (achieved 81% predicted heart rate compared to 85%) showed no evidence of ischemia but findings suggestive of hemodynamically significant dynamic mitral valve regurgitation with exercise. At rest, there was mild MR with estimated pulmonary artery systolic pressure (PASP) 30-35 mmHg with peak TRV of 2 m/s. On peak exercise, her MR worsened to at least moderate with an estimated PASP of 60-65 mmHg based on a TRV of 3.5 m/s. Cardiac magnetic resonance imaging showed no evidence of myocardial ischemia, fibrosis, or infiltration. The patient thereby underwent supine bicycle exercise right heart catheterization (RHC) (Table), which showed a negative mean pulmonary artery pressure/cardiac output (mPAP/CO) slope. Discussion: The patient qualifies for the diagnosis of EiPH based on the previous criteria, but the current criteria do not clarify how to interpret a negative mPAP/CO slope. In a patient with true pulmonary vascular disease, CO may go down during exercise, which may lead to a negative slope. This raises a question about the reconsideration of the current diagnostic methods.

Volume

212

Issue

S1

First Page

S4134

Last Page

S4134

Comments

American Thoracic Society International Conference, May 15-20, 2026, Orlando, FL

DOI

10.1093/ajrccm/aamag162.5523

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