Pulmonary hypertension resident survival guide: Difference between revisions
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==Don'ts== | ==Don'ts== | ||
* Do not perform vasospastic testing for those with overt heart failure or hemodynamic instability. | |||
==References== | ==References== | ||
Revision as of 03:44, 9 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]
Definition
Pulmonary hypertension (PH) is defined by mean pulmonary artery pressure > 25, pulmonary capillary wedge pressure (PCWP), left atrial pressure, or left ventricular end-diastolic pressure (LVEDP) ≤ 15 mm Hg; and a pulmonary vascular resistance (PVR) > than 3 Wood units. [1]
Causes
Life threatening causes
Life threatening conditions which may cause death or permanent disability within 24 hours if left untreated.
- Pulmonary veno-occlusive disease (PE)
Common causes
- Cor pulmonale (Right heart failure due to pulmonary disease)
- Congestive heart failure
- Congenital heart disease with left→right shunt (ASD, VSD, PDA).
- Lung diseases with chronic hypoxia (COPD, Obstructive sleep apnea, Interstital lung disease)
- Pulmonary hypertension due to thrombotic or embolic disease.
Management
Characterize the symptoms: ❑ Progressive dyspnea ❑ Exertional dizziness and syncope ❑ Edema of the extremities ❑ Anginal pain ❑ Palpitations | |||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Loud P2 (Pulmonary second heart sound) ❑ Systolic murmur from Tricuspid regurgitation ❑ Raised JVP (Jugular venous pressure) ❑ Peripheral edema ❑ Ascites | |||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Left sided heart failure ❑ Coronary artery disease ❑ Liver disease ❑ Budd-chiari syndrome | |||||||||||||||||||||||||||||||||||||||
| Acute vasoreactivity testing | |||||||||||||||||||||||||||||||||||||||
| Positive | Negative | ||||||||||||||||||||||||||||||||||||||
| Oral Calcium channel blocker (CCB) | Lower risk | Higher risk | |||||||||||||||||||||||||||||||||||||
| No | |||||||||||||||||||||||||||||||||||||||
| Sustained response | ❑ Endothelin receptor antagonsists (ERA's) or Phospodiesterase-5 inhibitors (PDE-5 Is) ((Oral) ❑ Epoprostenol or Treprostinil (IV) ❑ Illoprost (inhaled) ❑ Treprostinil (SC) | ❑ Epoprostenol or Treprostinil (IV) ❑ Illoprost (inhaled) ❑ ERAs or PDE-5 Is ((Oral) ❑ Treprostinil (SC) | |||||||||||||||||||||||||||||||||||||
| Yes | |||||||||||||||||||||||||||||||||||||||
| ↓ | |||||||||||||||||||||||||||||||||||||||
| Continue CCB | Reassess consider combo-therapy | Atrial septostomy Lung transplant | |||||||||||||||||||||||||||||||||||||
| ↓ | |||||||||||||||||||||||||||||||||||||||
| Investigational protocols | |||||||||||||||||||||||||||||||||||||||
The following guideline is based on Expert consensus document on pulmonary hypertension published by ACCF/AHA in 2009.[2]
Do's
- The diagnosis of Pulmonary hypertension requires confirmation with a right heart catheterization.
Don'ts
- Do not perform vasospastic testing for those with overt heart failure or hemodynamic instability.
References
- ↑ Kiely, DG.; Elliot, CA.; Sabroe, I.; Condliffe, R. (2013). "Pulmonary hypertension: diagnosis and management". BMJ. 346: f2028. PMID 23592451.
- ↑ McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR; et al. (2009). "ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association". Circulation. 119 (16): 2250–94. doi:10.1161/CIRCULATIONAHA.109.192230. PMID 19332472.