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Torbicki A, Kurzyna M. The Diagnostic Approach to Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:728-737. [PMID: 37487526 DOI: 10.1055/s-0043-1770116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
The clinical presentation of pulmonary hypertension (PH) is nonspecific, resulting in significant delays in its detection. In the majority of cases, PH is a marker of the severity of other cardiopulmonary diseases. Differential diagnosis aimed at the early identification of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) who do require specific and complex therapies is as important as PH detection itself. Despite all efforts aimed at the noninvasive assessment of pulmonary arterial pressure, the formal confirmation of PH still requires catheterization of the right heart and pulmonary artery. The current document will give an overview of strategies aimed at the early diagnosis of PAH and CTEPH, while avoiding their overdiagnosis. It is not intended to be a replica of the recently published European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines on Diagnosis and Treatment of Pulmonary Hypertension, freely available at the Web sites of both societies. While promoting guidelines' recommendations, including those on new definitions of PH, we will try to bring them closer to everyday clinical practice, benefiting from our personal experience in managing patients with suspected PH.
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Affiliation(s)
- Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre for Postgraduate Medical Education at ECZ-Otwock, Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre for Postgraduate Medical Education at ECZ-Otwock, Otwock, Poland
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Szabo B, Tanczos B, Varga A, Barath B, Ghanem S, Rezsabek Z, Al-Smadi MW, Nemeth N. Micro-Rheological Changes of Red Blood Cells in the Presence of an Arterio-Venous Fistula or a Loop-Shaped Venous Graft in the Rat. Front Physiol 2020; 11:616528. [PMID: 33391035 PMCID: PMC7775550 DOI: 10.3389/fphys.2020.616528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction: In case of kidney failure, hemodialysis is the primary kidney replacement technique. Several vascular access methods used for the therapy, one of which is the arterio-venous fistula (AVF). In the AVF, the blood flow is altered, which can elevate the mechanical stress on the red blood cells (RBCs). This can affect the RBC hemorheological properties, and it can further cause systemic changes. To lower the turbulence and shear stress, we performed a loop-shaped arterio-arterial venous interposition graft (loop-shaped graft) to compare its effect to the conventional AVF. Materials and Methods: Thirty male Wistar were used (permission registration Nr.: 25/2016/UDCAW). The animals were randomly divided into sham-operated, AVF, and loop groups (n = 10/each). The superficial inferior epigastric vein (SIEV) was used to create the AVF and the loop-shaped graft. Blood samples were taken before/after the surgery and at the 1st, 3rd, and 5th postoperative weeks. We measured hemorhelogical, hematological, and blood gas parameters. The microcirculation of the hind limbs was also monitored using Laser Doppler fluxmetry. Results: Hematocrit, RBC count, and hemoglobin decreased by the 1st postoperative week. The erythrocyte aggregation values significantly increased in the fistula group by the 5th week (6.43 ± 2.31 vs. 13.60; p < 0.0001; vs. before operation). At the postoperative 1st week in the loop group, the values showed a significant decrease in RBC deformability. During the maturation period, dominantly at the 5th week, all values were normalized. The operated hind limb's skin microcirculation significantly increased in the sham and loop group by the 1st week (39 ± 10.57 vs. 73.93 ± 1.97 BFU, p < 0.01). This increase wasn't observed in the fistula group probably due to a steal-effect. Conclusion: Unlike in the loop group, in the presence of the fistula, several rheological parameters have changed. The loop-shaped graft had only minimal impact on micro-rheological parameters.
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Affiliation(s)
- Balazs Szabo
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Bence Tanczos
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Adam Varga
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Barbara Barath
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Souleiman Ghanem
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsofia Rezsabek
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Mohammad Walid Al-Smadi
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Norbert Nemeth
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Lange TJ, Borst M, Ewert R, Halank M, Klose H, Leuchte H, Meyer FJ, Seyfarth HJ, Skowasch D, Wilkens H, Held M. [Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]. Pneumologie 2020; 74:847-863. [PMID: 32663892 DOI: 10.1055/a-1199-1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.
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Affiliation(s)
- T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - M Borst
- Medizinische Klinik I, Caritas-Krankenhaus, Bad Mergentheim
| | - R Ewert
- Pneumologie, Uniklinik Greifswald, Greifwald
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, München
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg
| | - M Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Klinikum Würzburg Mitte, Standort Missioklinik, Würzburg
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Blood carbon dioxide tension and risk in pulmonary arterial hypertension. Int J Cardiol 2020; 318:131-137. [DOI: 10.1016/j.ijcard.2020.06.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
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Ruocco G, Gavazzi A, Gonnelli S, Palazzuoli A. Pulmonary arterial hypertension and heart failure with preserved ejection fraction: are they so discordant? Cardiovasc Diagn Ther 2020; 10:534-545. [PMID: 32695633 DOI: 10.21037/cdt-19-405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) and pulmonary arterial hypertension (PAH) are two emerging diseases focusing the attention of numerous researchers. In the last PAH guideline, there is a crossroad between the two diseases and pulmonary hypertension (PH) due to heart failure (HF) is categorized as subtype 2. In order to assess the correct diagnosis and management, it should be better understood the points of convergence and divergence of two diseases. Although, risk factors, demographic characteristics and haemodynamics are different, we report several similarities regarding vascular alterations, some aspects of cardiac remodelling, and clinical presentation. This model suggests HFpEF and PAH as two comparable conditions, with different cardiac adaptation and trajectories, linked to the intrinsic properties of either right and left ventricles. In both diseases the early pathophysiological mechanisms appear to begin from peripheral vasculature and to be backward transmitted to the larger arterial vascular district, and eventually to the myocardial structure. In this paper we would propose a simple approach to recognize the concordances and, all at once, distinguish the peculiarities of the two diseases.
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Affiliation(s)
- Gaetano Ruocco
- Cardiology Unit, Regina Montis Regalis Hospital, ASLCN1, Mondovì (Cuneo), Italy
| | - Antonello Gavazzi
- FROM Research Foundation of the Bergamo Hospital, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Stefano Gonnelli
- Cardiovascular Diseases Unit, Department of Internal Medicine, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, Le Scotte Hospital, University of Siena, Siena, Italy
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Diaphragm function does not independently predict exercise intolerance in patients with precapillary pulmonary hypertension after adjustment for right ventricular function. Biosci Rep 2019; 39:BSR20190392. [PMID: 31427479 PMCID: PMC6723707 DOI: 10.1042/bsr20190392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/19/2019] [Accepted: 07/30/2019] [Indexed: 11/22/2022] Open
Abstract
Background: Several determinants of exercise intolerance in patients with precapillary pulmonary hypertension (PH) due to pulmonary arterial hypertension and/or chronic thromboembolic PH (CTEPH) have been suggested, including diaphragm dysfunction. However, these have rarely been evaluated in a multimodal manner. Methods: Forty-three patients with PH (age 58 ± 17 years, 30% male) and 43 age- and gender-matched controls (age 54 ± 13 years, 30% male) underwent diaphragm function (excursion and thickening) assessment by ultrasound, standard spirometry, arterial blood gas analysis, echocardiographic assessment of pulmonary artery pressure (PAP), assay of amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and cardiac magnetic resonance (CMR) imaging to evaluate right ventricular systolic ejection fraction (RVEF). Exercise capacity was determined using the 6-min walk distance (6MWD). Results: Excursion velocity during a sniff maneuver (SniffV, 4.5 ± 1.7 vs. 6.8 ± 2.3 cm/s, P<0.01) and diaphragm thickening ratio (DTR, 1.7 ± 0.5 vs. 2.8 ± 0.8, P<0.01) were significantly lower in PH patients versus controls. PH patients with worse exercise tolerance (6MWD <377 vs. ≥377 m) were characterized by worse SniffV, worse DTR, and higher NT-pro-BNP levels as well as by lower arterial carbon dioxide levels and RVEF, which were all univariate predictors of exercise limitation. On multivariate analysis, the only independent predictors of exercise limitation were RVEF (r = 0.47, P=0.001) and NT-proBNP (r = −0.27, P=0.047). Conclusion: Patients with PH showed diaphragm dysfunction, especially as exercise intolerance progressed. However, diaphragm dysfunction does not independently contribute to exercise intolerance, beyond what can be explained from right heart failure.
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Kovacs G, Dumitrescu D, Barner A, Greiner S, Grünig E, Hager A, Köhler T, Kozlik-Feldmann R, Kruck I, Lammers AE, Mereles D, Meyer A, Meyer J, Pabst S, Seyfarth HJ, Sinning C, Sorichter S, Stähler G, Wilkens H, Held M. Definition, clinical classification and initial diagnosis of pulmonary hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:11-19. [DOI: 10.1016/j.ijcard.2018.08.083] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/26/2022]
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Kovacs G, Avian A, Foris V, Tscherner M, Kqiku X, Douschan P, Bachmaier G, Olschewski A, Matucci-Cerinic M, Olschewski H. Use of ECG and Other Simple Non-Invasive Tools to Assess Pulmonary Hypertension. PLoS One 2016; 11:e0168706. [PMID: 28030578 PMCID: PMC5193419 DOI: 10.1371/journal.pone.0168706] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 12/04/2016] [Indexed: 01/27/2023] Open
Abstract
Background There is a broad consensus that pulmonary hypertension (PH) is to be diagnosed by right heart catheterization (RHC) and that the most important non-invasive tool is echocardiography. However, the role of simple non-invasive tools in the work-up of PH is not clearly defined. We hypothesized that the use of simple non-invasive techniques may help to guide important decisions in the diagnostics of pulmonary hypertension. Objectives We aimed to develop an algorithm with the use of simple, non-invasive tools in order to identify patients with very high or very low likelihood of PH. Methods We retrospectively analyzed all consecutive patients undergoing RHC between 2005 and 2010 in our center and performed logistic regression of simple non-invasive parameters regarding detection and exclusion of PH and derived a two-step algorithm. In a prospective study we evaluated this algorithm between 2011 and 2013. Results The retrospective cohort consisted of n = 394 patients of which 49% presented with PH. Right axis deviation in the ECG was present in 90/394 patients and had a positive predictive value (PPV) of 93% for PH. The combination of non-right axis deviation, N-terminal pro brain natriuretic peptide (NT-proBNP)<333pg/ml, arterial oxygen saturation (SO2)≥95.5% and WHO functional class I-II was present in 69/394 patients and excluded PH with a negative predictive value (NPV) of 96%. The prospective study confirmed these results in a cohort of n = 168 patients (PPV:92%, NPV:97%). Taken together, simple non-invasive tools allowed a prediction regarding the presence or absence of PH in 42% of patients with suspected PH. Conclusion ECG, NT-proBNP, SO2 and WHO functional class may predict the presence or absence of PH in almost half of the patients with suspected PH, suggesting an important role for these variables in the work-up of patients at risk for PH. Clinical Trial Registration NCT01607502
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Affiliation(s)
- Gabor Kovacs
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- * E-mail:
| | - Alexander Avian
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Medical University of Graz, Institute for Medical Informatics, Statistics and Documentation, Graz, Austria
| | - Vasile Foris
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Maria Tscherner
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Xhylsime Kqiku
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
| | - Philipp Douschan
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gerhard Bachmaier
- Medical University of Graz, Institute for Medical Informatics, Statistics and Documentation, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Medical University of Graz, Institute for Physiology, Graz, Austria
| | - Marco Matucci-Cerinic
- Department of Biomedicine, Division of Rheumatology, AOUC and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Horst Olschewski
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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Richter MJ, Tiede SL, Sommer N, Schmidt T, Seeger W, Ghofrani HA, Schermuly R, Gall H. Circulating Angiopoietin-1 Is Not a Biomarker of Disease Severity or Prognosis in Pulmonary Hypertension. PLoS One 2016; 11:e0165982. [PMID: 27802345 PMCID: PMC5089726 DOI: 10.1371/journal.pone.0165982] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Circulating angiopoietin-1 (Ang-1) has been linked to pulmonary hypertension (PH) in experimental studies. However, the clinical relevance of Ang-1 as a biomarker in PH remains unknown. We aimed to investigate the prognostic and clinical significance of Ang-1 in PH using data from the prospectively recruiting Giessen PH Registry. Methods Patients with suspected PH (without previous specific pulmonary arterial hypertension [PAH] therapy) who underwent initial right heart catheterization (RHC) in our national referral center between July 2003 and May 2012 and who agreed to optional biomarker analysis were included if they were diagnosed with idiopathic PAH, connective tissue disease-associated PAH (CTD-PAH), PH due to left heart disease (PH-LHD), or chronic thromboembolic PH (CTEPH), or if PH was excluded by RHC (non-PH controls). The association of Ang-1 levels with disease severity (6-minute walk distance and pulmonary hemodynamics) was assessed using linear regression, and the impact of Ang-1 levels on transplant-free survival (primary endpoint) and clinical worsening was assessed using Kaplan—Meier curves, receiver operating characteristic (ROC) analyses, and Cox regression. Results 151 patients (39, 39, 32, and 41 with idiopathic PAH, CTD-PAH, PH-LHD, and CTEPH, respectively) and 41 non-PH controls were included. Ang-1 levels showed no significant difference between groups (p = 0.8), and no significant associations with disease severity in PH subgroups (p ≥ 0.07). In Kaplan—Meier analyses, Ang-1 levels (stratified by quartile) had no significant impact on transplant-free survival (p ≥ 0.27) or clinical worsening (p ≥ 0.51) in PH subgroups. Regression models found no significant association between Ang-1 levels and outcomes (p ≥ 0.31). ROC analyses found no significant cut-off that would maximize sensitivity and specificity. Conclusions Despite a strong pathophysiological association in experimental studies, this first comprehensive analysis of Ang-1 in PH subgroups suggests that Ang-1 is not a predictive and clinically relevant biomarker in PH.
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Affiliation(s)
- Manuel Jonas Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
| | - Svenja Lena Tiede
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Natascha Sommer
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Thomas Schmidt
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- Department of Pneumology, Kerckhoff Heart, Rheuma and Thoracic Center, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Ralph Schermuly
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany
- * E-mail:
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Rosenkranz S, Gibbs JSR, Wachter R, De Marco T, Vonk-Noordegraaf A, Vachiéry JL. Left ventricular heart failure and pulmonary hypertension. Eur Heart J 2016; 37:942-54. [PMID: 26508169 PMCID: PMC4800173 DOI: 10.1093/eurheartj/ehv512] [Citation(s) in RCA: 432] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/20/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022] Open
Abstract
In patients with left ventricular heart failure (HF), the development of pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequent and have important impact on disease progression, morbidity, and mortality, and therefore warrant clinical attention. Pulmonary hypertension related to left heart disease (LHD) by far represents the most common form of PH, accounting for 65-80% of cases. The proper distinction between pulmonary arterial hypertension and PH-LHD may be challenging, yet it has direct therapeutic consequences. Despite recent advances in the pathophysiological understanding and clinical assessment, and adjustments in the haemodynamic definitions and classification of PH-LHD, the haemodynamic interrelations in combined post- and pre-capillary PH are complex, definitions and prognostic significance of haemodynamic variables characterizing the degree of pre-capillary PH in LHD remain suboptimal, and there are currently no evidence-based recommendations for the management of PH-LHD. Here, we highlight the prevalence and significance of PH and RV dysfunction in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), and provide insights into the complex pathophysiology of cardiopulmonary interaction in LHD, which may lead to the evolution from a 'left ventricular phenotype' to a 'right ventricular phenotype' across the natural history of HF. Furthermore, we propose to better define the individual phenotype of PH by integrating the clinical context, non-invasive assessment, and invasive haemodynamic variables in a structured diagnostic work-up. Finally, we challenge current definitions and diagnostic short falls, and discuss gaps in evidence, therapeutic options and the necessity for future developments in this context.
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Affiliation(s)
- Stephan Rosenkranz
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937 Köln, Germany Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Köln, Germany
| | - J Simon R Gibbs
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital London, London, UK
| | - Rolf Wachter
- Klinik für Kardiologie und Pneumologie, Herzzentrum, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Germany German Cardiovascular Research Center (DZHK), Göttingen, Germany
| | - Teresa De Marco
- Division of Cardiology, University of California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Jean-Luc Vachiéry
- Department of Cardiology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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