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Pulmonary Hypertension: Overview. Pulmonary Hypertension (PH) is an under-recognized disease PH is estimated to be the third most common cardiovascular syndrome Is the result of pulmonary, cardiac, infectious, and connective tissue disease Treatment varies based on etiology. - PowerPoint PPT Presentation
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Pulmonary Hypertension: Overview
Pulmonary Hypertension (PH) is an under-recognized disease
PH is estimated to be the third most common cardiovascular syndrome
Is the result of pulmonary, cardiac, infectious, and connective tissue disease
Treatment varies based on etiology
Pulmonary Arterial Hypertension: Definition Pulmonary arterial hypertension (PAH) is a
progressive, incurable disease of the small pulmonary arteries characterized by vascular cell proliferation, aberrant remodeling, and thrombosis in situ
PH is defined as a combination of: Mean pulmonary artery pressure > or =25mmHg
at rest Mean pulmonary artery pressure > or =30mmHg
with exercise
Vascular Pressure in Systemic and Pulmonary Circulations (mm Hg)
PulmonaryCirculation
Systemic Circulation
Arteries Arteries
Veins Veins
120/80, mean 90 25/10, mean 15
LeftAtriumMean 5
RightAtrium
Mean >6
RightVentricle
25/5
LeftVentricle
120/5
LungBody
SVR= 17.6 PVR= 1.8
WHO Clinical Classification of PH
Group 1. Pulmonary arterial hypertension
Group 2. Pulmonary venous hypertension
Group 3. PH associated with disorders of the respiratory system and/or hypoxemia
Group 4. PH due to chronic thromboembolic disease
Group 5. Miscellaneous
KDMC Statistics FY 08
130115
4
297
162
41
416
314
41
0
50
100
150
200
250
300
350
400
450
415.0-415.19 416.8 416.0-416.9
Inpatient Outpatient ED
415.0-415.9 (Acute Pulm Heart Disease – includes Cor Pulmonale, Pulm Embolism)
416.8 (PH, Secondary)
416.0 – 416.9 (Chronic Pulm Heart Disease – includes all types of PH, Cor Pulmonale)
KDMC Statistics FY07 – FY08
84
115
79
162
122
314
0
50
100
150
200
250
300
350
415.0-415.19 416.8 416.0-416.9
FY07F08
5 48
41
11
41
0
5
10
15
20
25
30
35
40
45
415.0-415.19 416.8 416.0-416.9
FY07F08
113130 126
297
233
416
0
50
100
150
200
250
300
350
400
450
415.0-415.19 416.8 416.0-416.9
FY07F08
Inpatient
Outpatient
Emergency Department
Appropriate Patient for Referral
Echo revealing: Pulmonary Artery (PA) Systolic Pressure >
40mmHg PA Systolic pressures between 35-40
mmHg when patient is symptomatic
Right Heart Cath revealing: Sustained Mean PA Pressure >25mmHg at
rest or >30 mmHg with exercise Mean pulmonary-capillary wedge pressure
and left ventricular end-diastolic pressure <15 mmHg
Appropriate Patient for Referral
CXR revealing pulmonary artery enlargement or pruning
EKG showing Right Ventricular strain
Required Documentation/Testing
Detailed Physician H&PComplete PFTVQ ScanCXREcho
Initial Clinic Visit
Assessment 12 lead EKG 6 Minute Walk Test Patient Education Additional Testing ordered as indicated Testing will be coordinated for minimal
patient inconvenience
Possible Additional Testing
Radiology HRCT of Thorax Pulmonary Angiogram
Labs: CBC with platelets BMP LFTs BNPEP Thyroid Function Panel ANA screen RF
Sed Rate CRP Scl-70 PT/INR Hypercoagulability
Panel HIV Antiphospholipid
Antibodies Sleep Study Right Heart Cath
Follow up Clinic Visit
All testing will be evaluated Patient follow up evaluation Diagnosis including WHO Group and
Functional Class Treatment Plan initiated Continual patient education Letter to referring physician detailing
findings and treatment plan
Multi-Departmental Support
Echo Lab Things to obtain and focus on when performing Things to obtain and focus on when performing
and interpreting and interpreting ALLALL Echocardiograms Echocardiograms A global evaluation of right heart structure and
function Right Ventricular systolic pressuresRight Ventricular systolic pressures Right Atrial and/or Ventricular enlargementRight Atrial and/or Ventricular enlargement
Diastolic DysfunctionDiastolic Dysfunction Valvular Heart DiseaseValvular Heart Disease, e.g. TR Ejection fractionEjection fraction Pericardial disease / Pericardial effusion
Multi-Departmental Support
Cath Lab Right Heart Cath protocols must be
followed in order to diagnose and obtain treatment
Right Heart Catheterization in PAH: Indications
Confirm presence of PH Aid to determining etiology Prognostication Guide therapeutic choices, e.g. CCBs Follow up therapeutic interventions
RHC in PAH:Key Findings PH: mean PAP ≥ 25mmHg at rest or ≥
30 mmHg with exercise PAWP <15 mmHg PVR >3 Wood Units Evidence of valvular heart disease Evidence of left-sided dysfunction Evidence of congenital heart disease
RHC in PAHSpecial Procedures
Vasodilator administrationFluid challengeExerciseShunt evaluation
Multi-Departmental Support
All Departments need to provide the best possible testing and timely reporting
These two aspects are crucial to treating these patients quickly and effectively
