Pulmonary hypertension due to left heart disease

Abstract

Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past 5 years since the 5th World Symposium on Pulmonary Hypertension in 2013, leading to a better understanding of PH-LHD, challenges and gaps in evidence. PH in heart failure with preserved ejection fraction represents the most complex situation, as it may be misdiagnosed with group 1 PH. Based on the latest evidence, we propose a new haemodynamic definition for PH due to LHD and a three-step pragmatic approach to differential diagnosis. This includes the identification of a specific “left heart” phenotype and a non-invasive probability of PH-LHD. Invasive confirmation of PH-LHD is based on the accurate measurement of pulmonary arterial wedge pressure and, in patients with high probability, provocative testing to clarify the diagnosis. Finally, recent clinical trials did not demonstrate a benefit in treating PH due to LHD with pulmonary arterial hypertension-approved therapies.

Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018

“…Patients with PH-LHD usually have post-capillary PH, which is defined by a mean pulmonary arterial pressure (mPAP) ≥25 mmHg and a pulmonary arterial wedge pressure (PAWP) N15 mmHg [2,3,8] ( Table 1).…”

“…Pulmonary hypertension (PH) due to left heart disease (PH-LHD; Nice group 2) is the most common form of PH and accounts for 48-80% of all cases [1][2][3][4]. PH-LHD can occur due to any type of left heart disease, including valvular or congenital heart disease, but it is International Journal of Cardiology 272 (2018) [53][54][55][56][57][58][59][60][61][62] most common in patients with heart failure and preserved (HFpEF) or reduced ejection fraction (HFrEF).…”

“…PH-LHD can occur due to any type of left heart disease, including valvular or congenital heart disease, but it is International Journal of Cardiology 272 (2018) [53][54][55][56][57][58][59][60][61][62] most common in patients with heart failure and preserved (HFpEF) or reduced ejection fraction (HFrEF). PH-LHD is associated with more severe symptoms and a lower exercise tolerance, and also has a negative impact on prognosis [2][3][4]. Patients with PH-LHDin particular those with HFpEFare usually older, female, and have a higher prevalence of cardiovascular comorbidities and several, if not all, components of the metabolic syndrome [5][6][7].…”

Cardiopulmonary exercise test predicts right heart catheterization

“…Therefore, the DPG (defined as diastolic PAPmean PAWP) appears to best approach the characteristics required to determine pulmonary vascular disease. 7,8 Besides this novel approach to PH, correlations between CPET and novel RHC parameters still remain less investigated. It is well known that in PAH, CPET parameters are characterized by severe reduction in peak VO 2 , work rate, O 2 pulse and anaerobic threshold and by a marked increase in VE/VCO 2 slope and in the dead space to tidal volume ratio.…”

The new haemodynamic definition of pulmonary hypertension: evidence prevails, finally!

“…For PH associated with left heart disease and lung disease, even with the current definition we have no specific PH treatment [30,31], so the revised definition should not change anything, except for better identifying patients in need of a therapy and helping to include them into future clinical trials. For pre-capillary PH, especially PAH, SIMONNEAU et al [5] reinforced the requirement of a pulmonary vascular resistance ⩾3 Wood units, which is currently the best criterion for pre-capillary pulmonary vascular disease.…”