Pulmonary hypertension in patients with left heart failure
- Udhay Krishnan, MD
Udhay Krishnan, MD
- Assistant Professor of Medicine
- Weill Cornell Medicine/Cornell University
- Evelyn Horn, MD
Evelyn Horn, MD
- Professor of Clinical Medicine
- Weill Cornell Medicine/Cornell University
Left-sided heart failure (left heart disease or LHD) is the most common cause of pulmonary hypertension (PH). This form of PH (henceforth described as PH due to left heart disease [PH-LHD]) can occur in patients with heart failure with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or HF caused by left-sided valvular disease. Recognition of PH-LHD is important because it is clearly associated with increased morbidity and mortality [1-7]; however, therapeutic strategies beyond treatment of the underlying LHD have not been well-established.
The prevalence, pathogenesis, evaluation, prognosis, and treatment of PH-LHD are discussed here. Evaluation and management of patients with HF are discussed separately. (See "Evaluation of the patient with suspected heart failure" and "Determining the etiology and severity of heart failure or cardiomyopathy" and "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
CLASSIFICATION AND DEFINITIONS
The World Health Organization has categorized PH, clinically, into five groups based on the underlying etiology for the disease . When all five groups are described collectively, the term PH is used. The term pulmonary arterial hypertension is used when referring to patients in group 1. Group 2 consists of patients with PH due to left heart disease (PH-LHD). A more detailed description of the classification of PH is discussed separately. (See "Classification and prognosis of pulmonary hypertension in adults", section on 'Classification'.)
PH has been defined as a resting mean pulmonary arterial pressure (mPAP) ≥25 mmHg on right heart catheterization. PH-LHD is defined hemodynamically as an mPAP ≥25 mmHg and a pulmonary capillary wedge pressure (PCWP) ≥15 mmHg .
PH-LHD has been characterized by various descriptors in the medical literature with subsequent adoption of more standardized definitions. Older terms have included pulmonary venous hypertension, out-of-proportion PH, mixed PH, and passive versus reactive PH. This confusing terminology stems from the complex nature of PH-LHD, which encompasses both patients with elevated mPAP from passive transmission of increased left-sided filling pressures to the pulmonary circulation, as well as patients with superimposed pulmonary vascular disease. The recommended nomenclature to describe these two subgroups, respectively, are isolated post-capillary PH and combined post- and precapillary PH , as described below. (See 'Right heart catheterization' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CLASSIFICATION AND DEFINITIONS
- CLINICAL MANIFESTATIONS
- Symptoms and signs
- Initial tests
- DIAGNOSIS AND EVALUATION
- When to suspect PH-LHD
- Approach to diagnosis and evaluation
- - Transthoracic echocardiography
- - Right heart catheterization
- - Exercise testing
- - Additional testing
- DIFFERENTIAL DIAGNOSIS
- PROGNOSTIC SIGNIFICANCE
- Optimized management of left heart disease
- - General approach
- - Vasodilator challenge as a guide for therapy
- Targeted therapy for pulmonary hypertension
- - Indications
- - Evidence
- Management of heart transplant candidates
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS