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Revision as of 16:25, 11 May 2021

Pulmonary Hypertension Microchapters

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Overview

Historical Perspective

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Causes

Differentiating Pulmonary hypertension from other Diseases

Epidemiology & Demographics

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Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] ; Assistant Editor(s)-in-Chief: Lisa Prior; Ralph Matar

Overview

Pulmonary hypertension (PH) can present with a myriad of physical findings that may be associated with PH or the underlying cause. Findings associated with pulmonary hypertension are usually associated with right heart failure or right heart overload, while other findings may be associated with underlying cause, such as thoracic deformities which may arise in the setting of COPD, or sclerodactyly that may be seen in patients with scleroderma. Some may develop on a spectrum corresponding to the severity of the disease.

Physical Examination

General Appearance

The appearance of the patient may give clues as to the etiology of the condition. For example in COPD, one of the most common causes of pulmonary hypertension, the patient may appear short of breath with pursed lips breathing and use of accessory muscles. Later on in severe disease, the patient may appear cyanotic with extremities cold to the touch.[1]

Pulse

The pulse may be diminished. This usually occurs in more severe disease.[1]

Skin

Jugular Venous Pressure - JVP

Assessment of the JVP in pulmonary hypertension involves assessing the 'a' wave (coincides with atrial contraction), the 'v' wave (coincides with atrial filling) and the height of the JVP column above the sternal angle. Physical findings may include:

Lungs

Cardiovascular

A complete precordial assessment of pulmonary hypertension involves palpating the precordium for heaves and thrills and ausculatating to assess first and second heart sounds, splitting of the second heart sound and determining if there any added heart sounds or murmurs. Physical findings may include the following:

Palpation

  • Left parasternal heave: due to hyperdynamic right ventricle
  • Palpable P2: correlates with severe disease [1]

Ausculation

First and second heart sound (S1,S2)
  • Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration.[3]
Splitting of S2
  • Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.[4]
  • Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.[3]
Extra Heart Sounds
  • S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
  • S3: if right ventricular failure develops. Increased with inspiration.[1]
Additional Sounds
  • Systolic pulmonary ejection click: increased with inspiration
Murmurs

Abdomen

Findings in the abdomen include:

  • Ascites: indicates right ventricular failure
  • Painful hepatomegaly: indicates right ventricular failure
  • Pulsatile liver: due to tricuspid regurgitation [1]

Extremities

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
  2. Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA; et al. (2009). "Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT)". Eur Heart J. 30 (20): 2493–537. doi:10.1093/eurheartj/ehp297. PMID 19713419.
  3. 3.0 3.1 Thompson, Paul Richard; Topol, Eric J.; Califf, Robert M.; Prystowsky, Eric N.; Thomas, James Alan (2007). Textbook of cardiovascular medicine. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7012-2.
  4. Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
  5. Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.

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