Current Diagnostic and Prognostic Assessment of Pulmonary Hypertension (original) (raw)
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Definitions and Diagnosis of Pulmonary Hypertension
Journal of the American College of Cardiology, 2013
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure !25 mm Hg at rest, measured during right heart catheterization. There is still insufficient evidence to add an exercise criterion to this definition. The term pulmonary arterial hypertension (PAH) describes a subpopulation of patients with PH characterized hemodynamically by the presence of pre-capillary PH including an end-expiratory pulmonary artery wedge pressure (PAWP) 15 mm Hg and a pulmonary vascular resistance >3 Wood units. Right heart catheterization remains essential for a diagnosis of PH or PAH. This procedure requires further standardization, including uniformity of the pressure transducer zero level at the midthoracic line, which is at the level of the left atrium. One of the most common problems in the diagnostic workup of patients with PH is the distinction between PAH and PH due to left heart failure with preserved ejection fraction (HFpEF). A normal PAWP does not rule out the presence of HFpEF. Volume or exercise challenge during right heart catheterization may be useful to unmask the presence of left heart disease, but both tools require further evaluation before their use in general practice can be recommended. Early diagnosis of PAH remains difficult, and screening programs in asymptomatic patients are feasible only in high-risk populations, particularly in patients with systemic sclerosis, for whom recent data suggest that a combination of clinical assessment and pulmonary function testing including diffusion capacity for carbon monoxide, biomarkers, and echocardiography has a higher predictive value than echocardiography alone. (J Am Coll Cardiol 2013;62: D42-50) ª 2013 by the American College of Cardiology Foundation Diagnosis and assessment of patients with pulmonary arterial hypertension (PAH) have been major topics at all previous world meetings on pulmonary hypertension (PH), with the last update coming from the 4th World Symposium on Pulmonary Hypertension (WSPH) held in 2008 in Dana Point, California (1). The recommendations from that conference were incorporated into the most recent international guidelines (2-4). During the 5th WSPH in 2013 in From the
Haemodynamic definitions and updated clinical classification of pulmonary hypertension
European Respiratory Journal
Since the 1st World Symposium on Pulmonary Hypertension (WSPH) in 1973, pulmonary hypertension (PH) has been arbitrarily defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterisation. Recent data from normal subjects has shown that normal mPAP was 14.0±3.3 mmHg. Two standard deviations above this mean value would suggest mPAP >20 mmHg as above the upper limit of normal (above the 97.5th percentile). This definition is no longer arbitrary, but based on a scientific approach. However, this abnormal elevation of mPAP is not sufficient to define pulmonary vascular disease as it can be due to an increase in cardiac output or pulmonary arterial wedge pressure. Thus, this 6th WSPH Task Force proposes to include pulmonary vascular resistance ≥3 Wood Units in the definition of all forms of pre-capillary PH associated with mPAP >20 mmHg. Prospective trials are required to determine whether this PH population might benefit from specific mana...
Advances in Pulmonary Hypertension, 2014
During the Fifth World Symposium on Pulmonary Hypertension, the working group on diagnosis and assessment was charged with evaluating the definition of pulmonary arterial hypertension (PAH) as it was established at the Fourth World Symposium. The group also covered related topics such as “borderline PAH,” exercise-induced PAH, and issues surrounding the measurement of pulmonary capillary wedge pressure (PCWP). The working group's discussion specifically addressed the following questions:Should pulmonary hypertension (PH) continue to be defined by a resting mean pulmonary artery pressure (MPAP) ≥25 mm Hg, and should the term “borderline PH” be introduced?Should exercise-induced PH be included as a subset of PH?Should pulmonary vascular resistance (PVR) be reintroduced in the definition of PAH?Is pulmonary artery wedge pressure (PAWP) of 15 mm Hg adequate to distinguish between pre- and post-capillary PH, and how should it be measured?Should fluid or exercise challenge be used to ...
Criteria for diagnosis of exercise pulmonary hypertension
European Respiratory Journal, 2015
The previous definition of exercise pulmonary hypertension (PH) with a mean pulmonary artery pressure (mPAP) >30 mmHg was abandoned because healthy individuals can exceed this threshold at high cardiac output (CO). We hypothesised that incorporating assessment of the pressure–flow relationship using the mPAP/CO ratio, i.e. total pulmonary resistance (TPR), might enhance the accuracy of diagnosing an abnormal exercise haemodynamic response.Exercise haemodynamics were evaluated in 169 consecutive subjects with normal resting mPAP ≤20 mmHg. Subjects were classified into controls without heart or lung disease (n=68) versus patients with pulmonary vascular disease (PVD) (n=49) and left heart disease (LHD) (n=52).TPR and mPAP at maximal exercise produced diagnostic accuracy with area under the receiver operating curve of 0.99 and 0.95, respectively, for discriminating controls versus patients with PVD and LHD. The old criterion of mPAP >30 mmHg had sensitivity of 0.98 but specificit...
Diagnosis and Assessment of Pulmonary Arterial Hypertension
Journal of the American College of Cardiology, 2009
The diagnosis and assessment of pulmonary arterial hypertension is a rapidly evolving area, with changes occurring in the definition of the disease, screening and diagnostic techniques, and staging and follow-up assessment. The definition of pulmonary hypertension has been simplified, and is now based on currently available evidence. There has been substantial progress in advancing the imaging techniques and biomarkers used to screen patients for the disease and to follow up their response to therapy. The importance of accurate assessment of right ventricular function in following up the clinical course and response to therapy is more fully appreciated. As new therapies are developed for pulmonary arterial hypertension, screening, prompt diagnosis, and accurate assessment of disease severity become increasingly important. A clear definition of pulmonary hypertension and the development of a rational approach to diagnostic assessment and follow-up using both conventional and new tools will be essential to deriving maximal benefit from our expanding therapeutic armamentarium.
Clinical features of human pulmonary hypertension
2011
printing supported by . Visit Chiesi at Stand D.30 WEDNESDAY, SEPTEMBER 28TH 2011 as the cutoff, we could distinguish IPAH from PHLHD with 97% sensitivity and 100% specificity. The area under the ROC curve was 0.99. Conclusion: Left atrial volume of 43 ml/m2 recorded by CMR may be a useful means of distinguishing between IPAH and PHLHD, avoiding the need for catheterisation. 4913 The changing picture of patients with pulmonary arterial hypertension (PAH) in France Olivier Sitbon1, Azzedine Yaïci1, Laurence Rottat1, Vincent Cottin2, Emmanuel Bergot3, Grégoire Prévot4, Virginie Gressin5, Marc Humbert1, Gérald Simonneau1. 1Centre de Référence de l’Hypertension Pulmonaire Sévère, APHP, Hôpital A. Béclère, Université Paris-Sud 11, Clamart, France; 2Service de Pneumologie, CHU, Hôpital Louis Pradel, Lyon, France; 3Service de Pneumologie, CHU, Hôpital de la Côte de Nacre, Caen, France; 4Service de Pneumologie, CHU, Hôpital Larrey, Toulouse, France; 5Actelion, Pharmaceuticals, Paris, France...
Haemodynamic evaluation of pulmonary hypertension
European Respiratory Journal, 2002
Pulmonary hypertension is characterised by the chronic elevation of pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) leading to right ventricular enlargement and hypertrophy. Pulmonary hypertension may result from respiratory and cardiac diseases, the most severe forms occurring in thromboembolic and primary pulmonary hypertension. Pulmonary hypertension is most often defined as a mean PAP >25 mmHg at rest or >30 mmHg during exercise, the pressure being measured invasively with a pulmonary artery catheter. Doppler echocardiography allows serial, noninvasive follow-up of PAPs and right heart function. When the adaptive mechanisms of right ventricular dilatation and hypertrophy cannot compensate for the haemodynamic burden, right heart failure occurs and is associated with poor prognosis. The haemodynamic profile is the major determinant of prognosis. In both primary and secondary pulmonary hypertension, special attention must be paid to the assessment of pulmonary vascular resistance index (PVRI), right heart function and pulmonary vasodilatory reserve. Recent studies have stressed the prognostic values of exercise capacity (6-min walk test), right atrial pressure, stroke index and vasodilator challenge responses, as well as an interest in new imaging techniques and natriuretic peptide determinations. Overall, careful haemodynamic evaluation may optimise new diagnostic and therapeutic strategies in pulmonary hypertension.
Pulmonary Hypertension Roundtable
Advances in Pulmonary Hypertension, 2005
In this discussion four experts shared insights on what might be considered the “gestalt” of diagnosing and monitoring pulmonary arterial hypertension. They ranged over a broad spectrum of issues that included thromboembolic pulmonary hypertension, exercise testing, hemodynamics, imaging studies, and response to therapy. The discussion was moderated by Vallerie V. McLaughlin, MD, Associate Professor of Medicine, Director, Pulmonary Hypertension Program, University of Michigan Health System, Ann Arbor, Michigan. The participants included Richard N. Channick, Associate Professor of Medicine, Pulmonary and Critical Care Division, University of California, San Diego Medical Center, San Diego, California; Ivan M. Robbins, MD, Director, Pulmonary Hypertension Center, Vanderbilt University, Nashville, Tennessee; and Victor F. Tapson, MD, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina.