Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• New Developments in the Diagnosis of Pulmonary Vascular Disease

  Medicine rarely advances in straight lines, and the pathway to identifying disease of the small arteries and veins supplying the lungs has been a textbook example. For decades, clinicians relied on a combination of clinical suspicion, transthoracic echocardiography, and right heart catheterisation to confirm pulmonary vascular disorders. Those tools remain pillars of practice, yet the last five years have produced a meaningful shift as imaging, biomarker science, and digital workflows open new doors for earlier and more accurate recognition.

  In Australia, where vast distances, intermittent exposure to bushfire smoke, and a strong tradition of mining and intensive livestock work create unusual risk profiles, that shift matters. Patients in regional Western Australia or far-north Queensland often travel for hours to reach a tertiary centre in Perth or Brisbane, so any diagnostic advance that compresses the journey to a diagnosis carries particular weight. The developments discussed below span hospitals in Sydney and Melbourne as much as outreach clinics linked to the Royal Flying Doctor Service.

  Imaging breakthroughs reshaping detection

  Computed tomography pulmonary angiography has long been the workhorse for ruling out pulmonary embolism, but newer generations bring something extra. Dual-energy CT scanners, increasingly available in major teaching hospitals such as the Royal Adelaide and the Royal Melbourne, can now map perfusion defects at the time of angiography. This dual readout sharpens the diagnosis of chronic thromboembolic pulmonary hypertension and helps separate acute from chronic clots in a single sitting.

  Cardiac magnetic resonance imaging has matured into a credible non-invasive window on the right heart. Sequences that quantify right ventricular mass, strain, and pulmonary artery distensibility allow repeat studies without radiation, a benefit when younger patients need ongoing surveillance. Pulmonary MR angiography and four-dimensional flow protocols are slowly moving from research scanners at the Victor Chang Cardiac Research Institute and Baker Heart and Diabetes Institute into mainstream reporting lists.

  Ventilation–perfusion scintigraphy retains a particular role in suspected chronic thromboembolic disease, where a single mismatched segmental defect still carries strong weight. SPECT cameras now produce tomographic slices rather than planar images, lifting diagnostic confidence and reducing indeterminate reads.

  Hemodynamic assessment beyond the catheter

  Right heart catheterisation remains the only way to definitively confirm pulmonary arterial hypertension. The procedure defines mean pulmonary artery pressure, pulmonary vascular resistance, and wedge pressure, and underpins decisions about calcium channel blocker suitability through vasoreactivity testing. Newer hybrid laboratories in Sydney's Liverpool Hospital and Melbourne's Alfred merge fluoroscopy with intracardiac pressure tracing, shortening case times and supporting safer workups.

  What is changing is who reaches the laboratory and when. Non-invasive haemodynamic proxies derived from echocardiography, including the tricuspid annular plane systolic excursion and ratios built on pulmonary artery diameters from CT, are reliably identifying patients who should be referred. Treadmill cardiopulmonary exercise testing adds a further layer, flagging reduced oxygen uptake and ventilatory inefficiency that tracks with vascular pathology rather than deconditioning alone.

  A practical workflow now sees a regional physician order an echocardiogram and an NT-proBNP, review the result through a Medicare-funded specialist video link, and refer only the patients who clear suspicion thresholds for catheter studies. That triage route has shortened time to diagnosis by several months in audit data published through the Thoracic Society of Australia and New Zealand.

  Biomarkers and molecular markers in clinical care

  A small panel of blood markers continues to anchor risk assessment, with NT-proBNP and BNP guiding urgency and treatment titration. Recent work has explored growth differentiation factor 15, circulating microRNAs, and endothelial-derived signals as complementary indicators. None have yet replaced existing assays, but several now sit alongside them in research protocols run through Australian biobanks.

  Key serum markers worth following in contemporary practice:

  • NT-proBNP and BNP for right ventricular strain and disease severity
  • Growth differentiation factor 15 as a marker of combined cardiac and systemic stress
  • Soluble ST2 and galectin-3 in exploratory and prognostic cohorts
  • Select microRNA panels under evaluation in pulmonary hypertension registries

  Workplace exposure history remains part of any meaningful work-up. In Australian settings, clinicians often ask about time in silica-exposed mining roles, exposure to cattle or grain dusts, and any recent travel through bushfire-affected regions, since each can shift pre-test probability and refine which tests to order.

  Reaching patients across remote and regional Australia

  Geography shapes how quickly pulmonary vascular disease is recognised. Patients living in regional towns such as Orange, Whyalla, or Broome can be hundreds of kilometres from a respiratory physician, and the Royal Flying Doctor Service bridges part of that gap for emergency transfers. Diagnostic work, however, is quieter and slower, which is where digital systems earn their place.

  Telehealth consultations funded through Medicare now allow physicians in Tennant Creek or Mount Isa to discuss imaging with a specialist in Adelaide or Melbourne in real time. Secure image-sharing platforms let CT scans taken in smaller hospitals be re-read at tertiary centres without duplicating radiation dose. Some sites also run mobile spirometry and pre-test screening through community health workers, helping identify symptomatic patients earlier.

  The Pharmaceutical Benefits Scheme influences which confirmatory tests are prioritised, since reimbursement of high-cost therapies often hinges on specific haemodynamic criteria. Knowing those criteria before ordering investigations can spare patients the frustration of repeating studies.

  Personalising risk for treatment selection

  Diagnosis is only the entry point; classification and risk are what guide treatment pathways. The 2022 European Society of Cardiology and European Respiratory Society guidelines, adapted locally by TSANZ, sort patients into low, intermediate, and high risk using a multi-domain approach that includes functional class, six-minute walk distance, cardiopulmonary exercise testing, biomarkers, and imaging.

  Risk calculators such as REVEAL 2.0 and COMPERA 2.0 have been validated in Australian cohorts, where the mix of connective tissue disease, congenital heart disease, and idiopathic disease produces a slightly different profile than northern hemisphere registries. Embedding these calculators into electronic records at hospitals such as the Royal Prince Alfred gives treating teams a consistent baseline and frames conversations about combination therapy, oral prostacyclin agents, and transplant referral.

  Risk domains commonly entered into contemporary calculators:

  • WHO functional class for symptom burden and exercise capacity
  • Six-minute walk distance or cardiopulmonary exercise testing for functional reserve
  • NT-proBNP for right ventricular strain and biochemical signal
  • Imaging parameters such as right ventricular function and pericardial effusion

  For a clinician planning to refresh their local pathway, the concrete next step is to download the current TSANZ position statement on pulmonary hypertension screening and align the regional echocardiography request template with its referral thresholds.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)