pulmonary hypertenttion recent PHT.pptx

pulmonary hypertension

1. Pulmonary hypertension made easy Dr / Waseem Omar, MD Lecturer of Cardiology, Al- Azhar University

2. Definition Mean pulmonary arterial pressure >25 mmHg, or a systolic pulmonary artery pressure of >40 mmHg at rest.

3. Methods of measurement Invasive: pulmonary artery catheters (i.e. Swan- Ganz catheter). Non invasive: assessment of TR velocity by continuous Doppler by echo (4 X TV2+ RAP).

4. Mechanisms of Pulmonary Hypertension Hypoxic vasoconstriction: chronic hypoxia causes pulmonary vasoconstriction. causes: COPD, chronic alveolar hypoxia. Decreased area of pulmonary vascular bed: causes: collagen vascular disease, HIV infection, drugs and toxins, thrombotic or embolic disease, inflammatory, interstitial fibrosis, • Volume and pressure overload pulmonary artery pressure will not rise in otherwise normal lung until pulmonary blood flow exceeds 2.5x the basal rate causes: congenital systemic-to-pulmonary shunts (e.g. VSD, ASD, PDA), portopulmonary HTN, left-sided heart conditions,

5. Classification I: Pulmonary Arterial HTN: Idiopathic Collagen vascular disease (scleroderma, SLE, RA) Congenital systemic-to-pulmonary shunts ( Eisenmenger syndrome) Portopulmonary HTN HIV infection Drugs and toxins (e.g. anorexigens ) Pulmonary veno -occlusive disease Schistosomiasis Sickle cell disease.

6. II: Pulmonary HTN due to Left Heart Disease Left-sided atrial or ventricular heart disease (e.g. LV dysfunction) Left-sided valvular heart disease (e.g. aortic stenosis, mitral stenosis)

7. III: Pulmonary HTN due to Lung Disease and/or Hypoxia. Parenchymal lung disease (COPD, interstitial fibrosis, cystic fibrosis) Chronic alveolar hypoxia (chronic high altitude, alveolar hypoventilation disorders, sleep-disordered breathing)

8. IV: Chronic Thromboembolic Pulmonary HTN (CTEPH) V: Pulmonary HTN with Unclear Multifactorial Mechanisms Hematologic disorders Systemic disorders (e.g. sarcoidosis ) Metabolic disorders Extrinsic compression of central pulmonary veins

9. Symptoms Symptoms of systemic congestion Dyspnea Fatigue Retrosternal chest pain Syncope Symptoms of underlying disease

10. Signs Loud, palpable P2 RV heave Right-sided S4 (due to RVH) Systolic murmur (tricuspid regurgitation) If RV failure: right sided S3, increased JVP, positive HJR, peripheral edema ,

11. Investigations CXR: enlarged central pulmonary arteries and attenuation of peripheral Vs ( bruning ), cardiac changes due to RV enlargement (filling of retrosternal air space). ECG: RVH/right-sided strain. 2-D echo doppler : assessment of right ventricular systolic pressure. Cardiac catheterization: direct measurement of pulmonary artery pressures (necessary to confirm diagnosis). PFTs: for assessmnet of underlying lung disease: CT angiogram: to assess lung parenchyma and possible PE. Serology: ANA positive in 30% of patients with primary pulmonary HTN;

12. General rules Mild physical activity Routine influenza and pneumococcal vaccine. Digoxin Anticoagulant Avoid high altitude. Oxygen therapy to maintain SO2 ≥ 90%. Diuretics. Contraception as PHT increase mortality by 30-50%.

13. Specific treatment I: No effective treatment CCBs. prostanoids , Endothelin receptor antagonists, PDE5 inhibitors Lung transplantation