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| COMMENTARY |
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| Ahead of print publication |
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Pulmonary hypertension - Basics
M Vishnu Sharma
Department of Respiratory Medicine, A J Institute of Medical Sciences, Mangalore, Karnataka, India
| Date of Submission | 08-Jun-2020 |
| Date of Decision | 29-Jun-2020 |
| Date of Acceptance | 03-Jul-2020 |
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Correspondence Address:
M Vishnu Sharma,
Department of Respiratory Medicine, A J Institute of Medical Sciences, Mangalore, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_322_20
Breathlessness can be a presenting symptom in a variety of diseases. Pulmonary hypertension (PH) is one of the underdiagnosed causes for breathlessness. Lack of awareness of this condition is the major reason for under diagnosis of PH.[1] Besides, majority of patients with PH may present with symptoms due to underlying disease, which leads to the development of PH.[2] Early diagnosis of PH, treatment of the underlying cause, and management of PH will prevent the complications and improve the long-term survival in these patients. In this issue of the Journal, in the article – Pulmonary Hypertension: A Simplified Pulmonologists Perspective – the authors have discussed these issues and the guidelines for diagnosis and management.
Diagnosis of PH requires a high index of suspicion and a stepwise approach.[1] PH should be considered as a differential diagnosis in any patient presenting with dyspnea on exertion, exercise intolerance, fatigue, syncope, and pedal edema.[2] Besides, one should be aware of the various disease conditions which will lead to the development of PH, most common being left heart failure and any chronic lung disease with hypoxia. Any patient having a risk factor or a disease which is known to result in PH should be evaluated.
Physical examination findings of right heart hypertrophy or right heart failure may not be evident in the early stages of PH. Chest radiographic abnormalities and electrocardiographic changes also may not be evident in the early stages of PH.[3]
A detailed transthoracic echocardiography should be performed in all patients with suspected PH.[4] Echocardiography is the best noninvasive, simplest investigation for diagnosis and estimation of severity of PH. Echo is also useful for early diagnosis of PH, as a screening tool to rule out PH in patients who are prone to develop PH as a complication of underlying diseases, follow-up of patients with PH, and assess the response to treatment.[4] Echo is also useful to assess the severity of right ventricular dysfunction which provides prognostic information.
Detailed history and physical examination with targeted investigations to find the underlying cause for PH should be carried out in all the patients diagnosed to have PH.[5] For this, one should be well versed with the various causes for PH. Discussion with a multidisciplinary team may be required for the diagnosis and management of PH when the cause is not obvious. It should be remembered that, in many patients, PH may be multifactorial in origin.
Pulmonary function test and computed tomographic scan thorax may be useful when underlying lung disease is suspected as the cause for PH.[5]
Right heart catheterization is indicated only in patients with pulmonary arterial hypertension (PAH) for definitive diagnosis, but the practice differs between centers.[3] Right heart catheterization is done only in very few centers in India.
Identification and proper management of the underlying cause for PH are the keys to improve the long-term survival and prevention of complications in PH.[5] In some cases, PH may be reversible with treatment. Pulmonary vasodilators are indicated only for patients with PAH.[6] Diuretics, supplemental oxygen, and digoxin form the supportive management in patients with severe PH, leading to right failure.[6]
| References | |  |
| 1. | Thenappan T, Ormiston ML, Ryan JJ, Archer SL. Pulmonary arterial hypertension: pathogenesis and clinical management. BMJ 2018;360:j5492.  |
| 2. | Dunlap B, Weyer G. Pulmonary hypertension: Diagnosis and treatment. Am Fam Physician 2016;94:463-9. |
| 3. | Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016;37:67-119. |
| 4. | Howard LS, Grapsa J, Dawson D, Bellamy M, Chambers JB, Masani ND, et al. Echocardiographic assessment of pulmonary hypertension: Standard operating procedure. Eur Respir Rev 2012;21:239-48. |
| 5. | Hambly N, Alawfi F, Mehta S. Pulmonary hypertension: Diagnostic approach and optimal management. CMAJ 2016;188:804-12. |
| 6. | Woodard TJ, Kim C, Siao FA, Review of the diagnosis and management of pulmonary arterial hypertension. US Pharm 2018;43:HS-10-15. |
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