Pulmonary hypertension resident survival guide: Difference between revisions
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Pulmonary hypertension (PH) is defined by mean pulmonary artery pressure > 25 mm Hg at rest.<ref name="Kiely-2013">{{Cite journal | last1 = Kiely | first1 = DG. | last2 = Elliot | first2 = CA. | last3 = Sabroe | first3 = I. | last4 = Condliffe | first4 = R. | title = Pulmonary hypertension: diagnosis and management. | journal = BMJ | volume = 346 | issue = | pages = f2028 | month = | year = 2013 | doi = | PMID = 23592451 }}</ref> | Pulmonary hypertension (PH) is defined by mean pulmonary artery pressure > 25 mm Hg at rest.<ref name="Kiely-2013">{{Cite journal | last1 = Kiely | first1 = DG. | last2 = Elliot | first2 = CA. | last3 = Sabroe | first3 = I. | last4 = Condliffe | first4 = R. | title = Pulmonary hypertension: diagnosis and management. | journal = BMJ | volume = 346 | issue = | pages = f2028 | month = | year = 2013 | doi = | PMID = 23592451 }}</ref> | ||
==Causes== | |||
===Life threatening causes=== | ===Life threatening causes=== | ||
Life threatening conditions which may cause death or permanent disability within 24 hours if left untreated. | Life threatening conditions which may cause death or permanent disability within 24 hours if left untreated. | ||
*Pulmonary veno-occlusive disease ([[PE]]) | *Pulmonary veno-occlusive disease ([[PE]]) | ||
===Common causes=== | ===Common causes=== | ||
* [[Cor pulmonale]] (Right heart failure due to pulmonary disease) | * [[Cor pulmonale]] (Right heart failure due to pulmonary disease) | ||
Revision as of 18:06, 7 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 mm Hg at rest.[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
Don'ts
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.