Based on 15 September 2016 AFP:
A patient has an echocardiogram as part of the evaluation for heart failure, and the PAP is 80. What can the FP do?
Definition: Pulm artery pressure > 25 mmHg.
Epidemiology: 20-80% of patients with L HF have PH. Patients with acute PE, 4% have PH in the acute phase.
There is no role for screening for PH, except in some patients with systemic sclerosis (scleroderma).
Five types of pulmonary hypertension:
- Pulmonary arterial hypertension (PAH) – formerly known as primary pulmonary hypertension. This is PH not caused by something else.
- The only type that the vasodilator drugs have strong evidence of efficacy for.
- Pulmonary hypertension secondary to L heart disease, systolic/diastolic dysfunction and valvular heart disease.
- Pulmonary hypertension secondary to lung disease (COPD, interstitial lung disease, OSA).
- If PAP is < 60mmHg, they should be on supplemental O2 to keep sats 92-94%.
- Pulmonary hypertension secondary to chronic VTE.
- Targeted treatment is pulmonary endarterectomy – can be curative. Lifelong anticoagulation.
- Multifactorial PH
- sickle cell, systemic CTD, metabolic disorders, others…
- Tx: hydroxyurea, transfusion
FPs can have the biggest role in optimizing treatment of Group 2 and 3 above!
- Dyspnea (especially on exertion)
- Incidentally found on echo for other reason
- Low SaO2
- TR murmur
- Lower extremity edema
- EKG: RBBB, R axis deviation
- EKG: S1/Q3/T3, RBBB, RAE
- Sleep study
- HIV, ANA, BNP, transaminases
- Functional status: 6min walk
Make sure patients are up to date on their immunizations!
Do a good preoperative eval (functional status, recent echo, PFTs) prior to surgery!
Three big classes medication:
- Endothelin receptor antagonists – bosentan, ambrisentan
- PDE-5 inhibitors: sildenafil, tadalafil