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Diagnosis of Pulmonary Hypertension

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Diagnosis of Pulmonary Hypertension

  1. 1. DIAGNOSIS 15098
  2. 2. When to suspect Pulmonary Hypertension •Any case of breathlessness without overt signs of specific heart and lung disease •Increased breathlessness unexplained by the underlying disease itself •Symptoms and/or physical signs of pulmonary hypertension in presence of co-morbid conditions like CTD / ILD, CHD with systemic to pulmonary shunt, portal hypertension, HIV infection, sleep apnea syndromes, deep vein thrombosis •Incidental suspicion via abnormal ECG , CXR echocardiographic finding .
  3. 3. The evaluation process of a patient with suspected PH requires a series of investigations intended to 1. confirm the diagnosis 2. clarify the clinical group of PH and the specific aetiology within the PAH group 3. evaluate the functional and haemodynamic impairment.
  4. 4. Clinical presentation • Dyspnea 60% • Fatigue 19% • Near syncope/syncope 13% • Chest pain 7% • Palpitations 5% • LE edema 3% • Hoarseness of voice 2% (Ortners syndrome) Symptoms of PAH
  5. 5. Physical Exam Findings in PH
  6. 6. Diagnostic Work-up of PAH
  7. 7. Electrocardiogram • RV hypertrophy and strain • Right atrial dilatation. • Right axis deviation • An R wave/S wave ratio greater than one in lead V1 • Incomplete or complete right bundle branch block • Increased P wave amplitude in lead II
  8. 8. Chest Radiograph In 90% of patients with IPAH the chest radiograph is abnormal at the time of diagnosis. Findings include •central pulmonary arterial dilatation •‘pruning’ (loss) of the peripheral blood vessels •Right atrium and RV enlargement
  9. 9. CXR in PH Large central Pulmonary arteries Right Ventricular Hypertrophy Rapid attenuation of pulmonary vessels Clear Lung Fields
  10. 10. Echocardiogram Transthoracic echocardiography provides several variables which correlate with right heart haemodynamics including PAP •Order for screening when clinical suspicion exists •Order for standard interval screening in selected groups: •Family of those with IPAH or with known BMPR2 mutation •Scleroderma spectrum •Pre-liver transplant
  11. 11. Echocardiogram Findings  TR  Right atrial and ventricular hypertrophy  Flattening of interventricular septum  Small LV dimension  Dilated PA  Pericardial effusion • Poor prognostic sign • RA pressure so high it impedes normal drainage from pericardium • Do not drain, usually does not induce tamponade since RV under high-pressure and non-collapsible
  12. 12. •Pulmonary function tests and arterial blood gases Pulmonary function tests and arterial blood gases will identify the contribution of underlying airway or parenchymal lung disease. •Ventilation/perfusion lung scan The ventilation/perfusion lung scan should be performed in patients with PH to look for potentially treatable CTEPH
  13. 13. •High-resolution CT High-resolution CT provides detailed views of the lung parenchyma and facilitates the diagnosis of interstitial lung disease and emphysema. Highresolution CT may be very helpful where there is a clinical suspicion of PVOD •Blood tests and immunology Routine biochemistry, haematology, and thyroid function tests are required in all patients. Serological testing is important to detect underlying CTD, HIV, and hepatitis. •Abdominal ultrasound scan Liver cirrhosis and/or portal hypertension can be reliably excluded by the use of abdominal ultrasound.
  14. 14. Right heart catheterization and vasoreactivity RHC is required •to confirm the diagnosis of PAH, •to assess the severity of the haemodynamic impairment, and •to test the vasoreactivity of the pulmonary circulation
  15. 15. •Mean PAP pressure •At rest: >25mmHg •With exercise: >30mmHg •Wedge Pressure: <15mmHg •Pulmonary Vascular Resistance: > 240 dynes- cm-sec-5
  16. 16. THANKS

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