Pulmonary hypertension misdiagnosis due to preventable errors in echocardiography and right heart catheterization
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Objectives
We hypothesized that preventable human errors in performance and reporting of transthoracic echocardiograms (TTEs) and right RHCs are common and may lead to misdiagnosis of pulmonary hypertension (PH) subgroups.
Background
PH is a common disease, however PH subgroups have vastly different mortality and treatment. This is particularly the case for pulmonary arterial hypertension (PAH) versus PH secondary to heart failure with preserved ejection fraction (HFpEF). TTE) and RHC are needed to differentiate these two diseases. Diagnosis requires specific cut-offs for mean pulmonary artery pressure (mPAP) and pulmonary artery wedge pressure (PAWP), which can only be measured by RHC. However, TTE first identifies PH, triggering referral to specialized PH centres.
Methods
We re-analyzed TTEs and RHCs of 252 PH program referrals over 5 years. We also compared the inferred diagnosis from the original reports to the diagnosis made after error correction.
Results
We identified numerous preventable errors in the performance and reporting of both tests, and subsequently there was a poor correlation between the parameters measured by both tests. The referral TTE reports missed or overcalled PH in 44 patients. The RHC, mostly by PAWP mistakes, led to misdiagnosis in 41 patients.
Conclusion
TTE errors may delay referrals, while RHC errors may lead to misdiagnosis and applying wrong therapies to patients. As PAH therapies are extremely expensive, this also impacts the health care system. Primary care physicians need to be on alert for such errors and referral centres need to promote quality improvement programs to mitigate these errors.
