Misdiagnosis of Pulmonary Hypertension Common Among Pulmonologists, Cardiologists

Enrico de Belen, MD

A simulation study assessing the care of patients with pulmonary hypertension is offering clinicians and health systems with insight into challenging aspects of care and areas for improvement in diagnosis.

A cross-sectional patient simulation study conducted among practicing cardiologists and pulmonologists, results of the study suggest clinical suspicious, nonspecific symptoms, and underuse of diagnostic tests all contributed to underdiagnosis of pulmonary hypertension, which was correctly suspected less than 50% of the time in the study.

“[Pulmonary hypertension], although uncommon, is an important, progressive, and potentially treatable disease, and misdiagnosis or late diagnosis can have dire consequences,” wrote investigators. “Our current understanding of how patients with [pulmonary hypertension] are evaluated is done retrospectively rather than dynamically as they go through the work-up and evaluation stages. We wanted to understand how these patients were evaluated and why diagnosis is often delayed or missed.”

Citing the reasoning mentioned above, the current study was launched with the intent of estimating the variation ion care provided by board-certified cardiologists and pulmonologists in simulated patients with potentially undiagnosed pulmonary hypertension. With this in mind, investigators designed a cross-sectional study to be conducted among 219 cardiologists and pulmonologists. In this simulation, patients presented with symptoms of chronic dyspnea and associated signs of potential pulmonary hypertension.

Investigators created 9 Clinical Performance and Value (CPV) cases to be cared for by participants, with these described as idiopathic pulmonary arterial hypertension, CTEPH, and pulmonary hypertension from left heart disease/congestive heart failure or from lung disease. Investigators noted these 3 case types each had 3 variants: an obvious pulmonary hypertension presentation, a more subtle pulmonary hypertension presentation, and a chronic dyspnea presentation that did not have pulmonary hypertension.

The primary outcomes of interest for the study were the quality-of-care scores assigned for work-up, diagnosis, and follow-up care of patients with suspected pulmonary hypertension. For the purpose of analysis, investigators scored clinical quality-of-care decision made in the simulated encounter against predetermined evidence-based criteria.

Of the 219 clinicians included in the study, 48.4% were cardiologists, 81.4% were men, and the mean age was 52.5±10.5 years. Investigators noted the majority of these patients worked in urban or suburban settings (93.9%), 83.8% worked in either an academic setting or private practice, and the average years of practice experience was 23.8±11.0 years.

Upon analysis, results indicated the quality-of-care scores achieved ranged from 18-74%, with a mean quality-of-care score of 43.2±11.5%. When pulmonary hypertension was present, it was correctly identified 49.1% of the time. In contrast, pulmonary hypertension was incorrectly identified in 53.7% of non-pulmonary hypertension cases.

Further analysis indicated 2-dimensional echocardiography was ordered by physicians in 64.3% of cases, with those ordering 2-dimensional echocardiography significantly more likely to get the presumptive diagnosis (61.9% vs 30.7%; P <.001). Investigators noted similar results were seen for those who ordered a ventilation/perfusion scan (81.5% vs 51.4%; P=.005) and high‐resolution computed tomography (60.4% vs 43.2%; P=.001). Investigators also pointed out those who correctly diagnosed pulmonary hypertension were significantly more likely to order confirmatory right heart catheterization or refer to pulmonary hypertension center (67.3% vs 15.8%; P <.001).

“This study shows that the diagnosis of [pulmonary hypertension] is often delayed or missed, primarily because of a low suspicion of [pulmonary hypertension] and underuse of key diagnostic tests and, when [pulmonary hypertension] is considered, failing to do a definitive right heart catheterization—all indicating an opportunity to improve the quality of care of patients with [pulmonary hypertension],” wrote investigators.

This study, “Gaps in the Care of Pulmonary Hypertension: A Cross-Sectional Patient Simulation Study Among Practicing Cardiologists and Pulmonologists,” was published in the Journal of the American Heart Association.