Medical Therapy for Heart Failure Associated With Pulmonary Hypertension

Abstract

The past 2 decades have witnessed a >40% improvement in mortality for patients with heart failure and left ventricular systolic dysfunction. 1 This success has coincided with the stepwise availability of drugs that target neurohormonal activation: β-adrenergic receptor blockers (β-blockers), ACE (angiotensin-converting enzyme) inhibitors and ANG (angiotensin) II blockers, neprilysin inhibitors, and aldosterone antagonists. Our understanding of right heart failure (RHF) has lagged behind and many proven targeted therapies for left heart failure do not appear to provide similar benefits for RHF. Until recently, the right ventricle (RV) has often been viewed as less important than the left ventricle and in contemporary literature received the moniker “The Forgotten Ventricle”. Recent advances in echocardiography and magnetic resonance imaging have enabled detailed assessments of RV anatomy and physiology in both health and disease allowing us to more accurately describe the clinical sequelae and end-organ manifestations of RHF. RV function is now recognized as one of the most important predictors of prognosis in many cardiovascular disease states. 2 Despite the significance of RV function to survival, there are no clinically approved therapies that directly nor selectively improve RV function. As well, relative to our understanding of left heart failure, the basis for RHF remains poorly understood. This article aims to condense the current knowledge on RV adaptation and failure, review current management strategies for RHF, and explore evolving therapeutic approaches.

Implication of inhaled nitric oxide for the treatment of critically ill COVID‐19 patients with pulmonary hypertension

“…Systolic function of the right ventricle is sensitive to changes in afterload, and small increases in pulmonary artery pressure can result in large reductions in stroke volume (SV). Therefore, reducing afterload of the right ventricle is the cornerstone of prevention and management of RVF due to pulmonary hypertension 9 . In our study, RHF occurred in both cases without iNO treatment, while not the three cases with iNO treatment, indicating that iNO treatment might reduce the risk of developing RHF in COVID‐19 patients as previously reported for the treatment of fat embolization syndrome 10 …”

“…Therefore, reducing afterload of the right ventricle is the cornerstone of prevention and management of RVF due to pulmonary hypertension. 9 In our study, RHF occurred in both cases without iNO treatment, while not the three cases with iNO treatment, indicating that iNO treatment might reduce the risk of developing RHF in COVID-19 patients as previously reported for the treatment of fat embolization syndrome. 10 Based on our study, we found that treatment with iNO was beneficial in reducing and stabilizing the PASP in the critically ill COVID-19 patients with pulmonary hypertension, especially in the early stage of pulmonary hypertension.…”

“…Pulmonary hypertension serves as the most common cause of RHF, which is the leading cause of death for pulmonary arterial hypertension. 9 Systolic function of the right ventricle is sensitive to changes in afterload, and small increases in pulmonary artery pressure can result in large reductions in stroke volume (SV). Therefore, reducing afterload of the right ventricle is the cornerstone of prevention and management of RVF due to pulmonary hypertension.…”

A Novel Non-Invasive Device for the Assessment of Central Venous Pressure in Hospital, Office and Home

“… 69–71 PH, defined by a mean pulmonary artery pressure (mPAP) ≥25 mm Hg at rest, is the most common cause of Right Heart Failure (RHF). 72 In patients with severe COVID-19, multiple concomitant mechanisms seem to contribute to the development of PH, this including cytokine storm, endothelial injury, hypercoagulability attributing to development of venous thromboembolism, worsening myocardial injury, and the presence of thrombotic microangiopathy. 70 …”

Metformin in Pulmonary Hypertension in Left Heart Disease

“…PH-LHD is defined as a mean pulmonary artery pressure of > 20 mmHg with a concomitant pulmonary artery wedge pressure of > 15 mmHg (7). As we uncover more about PH-LHD, it is becoming increasingly apparent that the pathophysiologic aberrations and the phenotypic variations are highly dependent on the underlying cardiovascular disease process, e.g., heart failure with reduced ejection fraction (HFrEF) vs. heart failure with preserved ejection fraction (HFpEF) (4, 7,8).…”