Echocardiographic assessment of pulmonary hypertension: a hierarchical interpretive framework for clinical...

Echocardiography is central to the evaluation of pulmonary hypertension (PH), yet interpretation of echocardiographic findings remains challenging because non-invasive estimation of pulmonary pressures and right ventricular function is inherently imperfect. Although contemporary guidelines provide structured probability-based assessment, the growing number of available echocardiographic parameters has increased interpretive complexity, particularly in routine echocardiography laboratories where findings must be integrated within diverse clinical contexts.

This narrative review synthesises contemporary echocardiographic parameters used in PH across key clinical applications, including screening, probability assessment, phenotyping, risk stratification, and longitudinal monitoring. Rather than cataloguing individual measurements, the review examines how pressure estimation, right ventricular structure and function, ventricular interaction, right atrial pressure surrogates, and integrative markers contribute differently according to the clinical question being addressed. Particular emphasis is placed on technical limitations, common sources of measurement uncertainty, and potential discordance with invasive haemodynamic assessment. Building on this synthesis, we propose a hierarchical, decision-oriented interpretive framework designed to support routine echocardiography laboratories by organising existing echocardiographic findings according to clinical purpose and interpretive confidence. The framework emphasises multiparametric integration, internal consistency, contextual interpretation, and transparent communication of uncertainty while complementing established guideline-based probability assessment.

A hierarchical interpretive approach positions echocardiography as a staged component of the broader pulmonary hypertension diagnostic and monitoring pathway rather than as a standalone diagnostic test. By supporting structured reporting, contextual interpretation, and consistent communication of uncertainty, the proposed framework complements existing international guidelines and may facilitate more consistent application of echocardiographic findings within routine clinical practice.