The Failing Right Ventricle : An Internist's Guide to the Diagnosis and Management of Pulmonary Hypertension

Abstract

Pulmonary hypertension represents a complex and multifactorial disease with significant implications on patients' morbidity, mortality, and quality of life. The number of patients hospitalized with pulmonary hypertension is increasing. Elevated pulmonary artery pressures as estimated by transthoracic echocardiogram are most commonly associated with left heart disease; however, careful attention and screening must be performed to promptly identify patients who may benefit from pulmonary vasodilator treatment. Early recognition and diagnosis of pulmonary hypertension is very important, but it can be challenging due to the nonspecific nature of patient symptoms and clinical findings. Furthermore, transthoracic echocardiogram does not always accurately estimate pulmonary artery pressures. Other clinical assessment tools such as computed tomography (CT) angiography of the chest and brain-type natriuretic peptide (BNP) levels can be helpful. Pulmonary hypertension is ultimately defined hemodynamically as a mean pulmonary artery pressure >20 mmHg, which is measured by right heart catherization. Following diagnostic evaluation, management of pulmonary hypertension and right ventricular failure focuses on optimizing right ventricular preload, afterload and contractility. A goal-directed approach to therapy helps guide treatment, and it helps identify patients who need escalation of therapy when goals are not being met. A goal-oriented approach to management improves outcomes and delays progression of pulmonary hypertension.