Pulmonary hypertension resident survival guide: Difference between revisions
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{{CMG}};{{AE}} {{ | {{CMG}}; {{AE}}, {{VB}} | ||
==Definition== | ==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. | 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. | ||
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==Causes== | ==Causes== | ||
===Life | ===Life Threatening Causes=== | ||
Life threatening conditions which may | Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. | ||
* | * [[Pulmonary embolism]] | ||
===Common | ===Common Causes=== | ||
* [[ | * [[Congenital heart disease]] with [[left-to-right shunt]] ([[ASD]], [[VSD]], [[PDA]]) | ||
* [[Congestive heart failure]] | * [[Congestive heart failure]] | ||
* [[ | * [[COPD]] | ||
* | * [[Cor pulmonale]] | ||
* [[Interstital lung disease]] | |||
* [[Obstructive sleep apnea]] | |||
* [[Thromboembolism]] | |||
==Management== | ==Management== | ||
Revision as of 16:00, 9 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: , Vidit Bhargava, M.B.B.S [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 causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Congenital heart disease with left-to-right shunt (ASD, VSD, PDA)
- Congestive heart failure
- COPD
- Cor pulmonale
- Interstital lung disease
- Obstructive sleep apnea
- Thromboembolism
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.
- Objective assessment of treatment measures includes:
- Exercise capacity.
- Hemodynamics.
- Survival.
- Epoprostenol is the only therapy that has been shown to prolong survival in patients with pulmonary hypertension.
- Monitor liver function tests monthly in patients being treated with endothelin receptor antagonists.
- Patients presenting with advanced symptoms, right heart failure, advanced hemodynamics and those on parenteral or combination therapy must be seen every 3 months.
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.