Pulmonary Hypertension

Created on Thu, 12/17/2015 - 23:16
Last updated on Thu, 11/02/2017 - 21:35

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In the past papers, pulmonary hypertension crops up now and then as a sideshow to some other major problems, or as a comorbidity to discuss. For instance, in Question 12 from the second paper of 2017 the patient has among other things pulmonary hypertension, and the candisates were asked to discuss their periop Question 2 from the second paper of 2015 asks the candidates to identify the causes of pulmonary hypetension. The update article by Siomonneau (2013) is an excellent resource for this answer, and is used to generate the table offered below. For a more thorough review of this disease process, one may look at the massive 2015 ESC/ERS Guidelines

Classification of pulmonary hypertension

The list used by the college answer is the updated 2013 Dana Point classification, which can be found in the Siomonneau article in Table 1. The objective of such a clasification was to join into groups pulmonary hypertensive diseases which share "similar pathological findings, similar hemodynamic characteristics and, similar management".

In brief, there are 5 major groups of disease which fall under the pulmonary hypertension heading:

  1. Pulmonary arterial hypertension 
    • associated with connective tissue disease
    • HIV
    • Congential or heriable
    • Drug-related
    • Due to portal hypertension
  2. Pulmonary hypertension due to left heart disease
    • ​LV systolic or diastolic dysfunction
    • Valve disease
    • Congential cardiomyopathies
  3. Pulmonary hypertension due to lung disease or hypoxia
    • COPD
    • Idiopathic pulmonary fibrosis
    • ​​OSA/obesity hypoventilation syndrome
    • Chronic exposure to high altitude
  4. Pulmonary hypertension due to chronic PE​​
  5. Pulmonary hypertension due to "unclear multifactorial mechanisms"
    • Myeloproliferative diseases
    • Haemolytic anaemias and MAHA
    • Sarcoidosis, pulmonary histiocytosis
    • Tumour obstruction
    • Fibrosing mediastinitis

Pulmonary arterial hypertension can also be subdivided into more categories:

Classification of pulmonary  arterial hypertension (PAH)'

Pulmonary Arterial Hypertension

Idiopathic PAH

  • Familial PAH
  • BMPR2 mutations (a member of the transforming growth factor β signaling family)

Drug and toxin induced PAH

  • Definite association: aminorex, fenfluramine, dexfenfluramine, toxic rapeseed oil
  • Possible association: cocaine, phenylpropanolamine, St Johns Wort, chemotherapy agents, SSRIs

Connective tissue disease

  • Systemic sclerosis
  • SLE
  • Sjogren syndrome
  • polymyositis
  • rheumatoid arthritis
HIV infection
  • clinical, hemodynamic, and histologic characteristics similar to those seen in idiopathic PAH
Portopulmonary hypertension
  • 2% to 6% of patients with portal hypertension have PAH
  • Pulmonary vascular resistance (PVR) is usually normal in these cases
Congential heart disease
  • systemic-to-pulmonary shunts
  • Eisenmenger syndrome
Schistosomiasis
  • Embolic obstruction of pulmonary arteries by schistosoma eggs
  • local vascular inflammation as a result of impacted schistosoma eggs
Chronic hemolytic anemia
  • sickle cell disease (SCD)
  • thalassemia
  • hereditary spherocytosis
  • stomatocytosis
  • microangiopathic hemolytic anemia
Left heart disease
  • LV failure
  • Mitral valve disease
Alveolar hypoxia
  • Alveolar hypoxia as a result of lung disease
  • Alveolar hypoxia due to impaired control of breathing (eg. OSA)\
  • Alveolar hypoxia due to residence at high altitude
Thromboembolism
  • obstruction of pulmonary arterial vessels by thromboemboli, tumors, or foreign bodies
Pulmonary hypertension due to unclear or multifactorial aetiologies
  • polycythemia vera
  • essential thrombocythemia
  • chronic myeloid leukemia
  • sarcoidosis
  • Langerhans histiocytosis
  • glycogen storage diseases
  • Gaucher disease
  • mediastinal fibrosis

 

References

Simonneau, Gérald, et al. "Updated clinical classification of pulmonary hypertension." Journal of the American College of Cardiology 54.1s1 (2009): S43-S54.

Simonneau, Gerald, et al. "Updated clinical classification of pulmonary hypertension." Journal of the American College of Cardiology 62.25 (2013): D34-D41.

Galiè, Nazzareno, et al. "2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension." European heart journal (2015): ehv317.