This document provides an overview of pulmonary hypertension (PH), including its definition, classification, pathophysiology, diagnostic workup, and treatment. PH is defined as a mean pulmonary arterial pressure over 25 mmHg at rest. It is classified into 5 groups, with Group 1 being pulmonary arterial hypertension. The pathophysiology involves vasoconstriction, endothelial dysfunction, and vascular remodeling. Diagnosis involves echocardiogram, right heart catheterization, and ruling out other causes. Treatment includes diuretics, anticoagulants, oxygen, and PAH-specific therapies, with the goal of improving functional status and survival.
Pulmonary hypertension (2014) dr.tinku josephDr.Tinku Joseph
This document provides information on pulmonary hypertension (PH), including its definition, classification, pathogenesis, diagnosis, and treatment. It begins with defining PH as a mean pulmonary arterial pressure greater than 25 mmHg at rest based on right heart catheterization. PH is classified into 5 groups. The pathogenesis and pathology of each group is described. Diagnostic workup includes labs, imaging like CXR, echocardiogram and right heart catheterization. Treatment involves general measures, diuretics, anticoagulants, oxygen, and PAH-specific therapies like endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and calcium channel blockers in some cases. Prognostic factors and goals of treatment are also discussed.
PowerPoint presentation describing various aspects of Pulmonary Hypertension. Please mail me your feedback on this presentation to following Email ID: tinkujoseph2010@gmail.com.
The document provides information on pulmonary hypertension and pulmonary circulation. It discusses:
1) The pulmonary circulation begins at the right ventricle and ends at the left atrium, transporting the entire cardiac output to the lungs. It has low resistance and high compliance.
2) Pulmonary artery pressures are normally lower than systemic pressures, with mean pulmonary artery pressure around 10-12 mmHg.
3) Pulmonary vascular resistance is low due to a balance of vasodilator and vasoconstrictor prostaglandins. Resistance primarily occurs in small arteries and arterioles.
4) Pulmonary hypertension is defined as a mean pulmonary artery pressure over 25 mmHg at rest. Its causes
The document discusses pulmonary hypertension and the pulmonary circulation. It provides details on:
1) The anatomy and physiology of the pulmonary circulation and how it differs from the systemic circulation with lower pressures and resistance.
2) The pathophysiology of pulmonary hypertension including abnormalities in the endothelium, smooth muscle cells, and vascular remodeling in different types.
3) Clinical definitions of pulmonary hypertension, pulmonary arterial hypertension, and evaluation tools like echocardiogram, CT, right heart catheterization.
4) Treatment involves vasodilators, diuretics, calcium channel blockers and general measures depending on the severity and type of pulmonary hypertension.
This document provides an overview of pulmonary hypertension (PH), including its definition, classification, mechanisms, pathology, clinical presentation, diagnosis, treatment, and prognosis. PH is defined as a mean pulmonary arterial pressure greater than 25 mm Hg at rest. It is classified into 5 groups based on etiology. Common mechanisms include vasoconstriction, vascular obstruction, increased blood flow, and loss of pulmonary vascular bed. Pathology often involves remodeling of small pulmonary arteries and arterioles. Presentation is usually nonspecific symptoms like dyspnea. Diagnosis involves echocardiogram, cardiac catheterization, and ruling out other causes. Treatment includes vasodilators, anticoagulation, diuretics, oxygen supplementation and sometimes
This document provides an overview of pulmonary hypertension (PH), including its classification, pathophysiology, clinical presentation, diagnostic evaluation, and treatment. PH is classified into 5 groups depending on its underlying cause. It results from increased pulmonary vascular resistance leading to right heart strain. Patients typically present with dyspnea and signs of right heart failure. Diagnosis requires right heart catheterization. Treatment focuses on supporting right ventricular function, optimizing volume status, decreasing afterload, and treating the underlying cause.
1. Pulmonary hypertension (PH) is defined as a mean pulmonary arterial pressure ≥ 25 mmHg at rest as assessed by right heart catheterization.
2. PH can be classified as pre-capillary or post-capillary based on pulmonary wedge pressure and pulmonary vascular resistance.
3. Treatment for PH targets three main pathways - nitric oxide-soluble guanylate cyclase-cGMP pathway, endothelin-1 pathway, and prostacyclin pathway. Medications include phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, prostacyclin analogs, and riociguat.
This presentation covers the methodology of evaluating CTEPH (chronic thromboembolic pulmonary hypertension) case. It starts from the basic concepts of Pulmonary hypertension.
Pulmonary hypertension (2014) dr.tinku josephDr.Tinku Joseph
This document provides information on pulmonary hypertension (PH), including its definition, classification, pathogenesis, diagnosis, and treatment. It begins with defining PH as a mean pulmonary arterial pressure greater than 25 mmHg at rest based on right heart catheterization. PH is classified into 5 groups. The pathogenesis and pathology of each group is described. Diagnostic workup includes labs, imaging like CXR, echocardiogram and right heart catheterization. Treatment involves general measures, diuretics, anticoagulants, oxygen, and PAH-specific therapies like endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and calcium channel blockers in some cases. Prognostic factors and goals of treatment are also discussed.
PowerPoint presentation describing various aspects of Pulmonary Hypertension. Please mail me your feedback on this presentation to following Email ID: tinkujoseph2010@gmail.com.
The document provides information on pulmonary hypertension and pulmonary circulation. It discusses:
1) The pulmonary circulation begins at the right ventricle and ends at the left atrium, transporting the entire cardiac output to the lungs. It has low resistance and high compliance.
2) Pulmonary artery pressures are normally lower than systemic pressures, with mean pulmonary artery pressure around 10-12 mmHg.
3) Pulmonary vascular resistance is low due to a balance of vasodilator and vasoconstrictor prostaglandins. Resistance primarily occurs in small arteries and arterioles.
4) Pulmonary hypertension is defined as a mean pulmonary artery pressure over 25 mmHg at rest. Its causes
The document discusses pulmonary hypertension and the pulmonary circulation. It provides details on:
1) The anatomy and physiology of the pulmonary circulation and how it differs from the systemic circulation with lower pressures and resistance.
2) The pathophysiology of pulmonary hypertension including abnormalities in the endothelium, smooth muscle cells, and vascular remodeling in different types.
3) Clinical definitions of pulmonary hypertension, pulmonary arterial hypertension, and evaluation tools like echocardiogram, CT, right heart catheterization.
4) Treatment involves vasodilators, diuretics, calcium channel blockers and general measures depending on the severity and type of pulmonary hypertension.
This document provides an overview of pulmonary hypertension (PH), including its definition, classification, mechanisms, pathology, clinical presentation, diagnosis, treatment, and prognosis. PH is defined as a mean pulmonary arterial pressure greater than 25 mm Hg at rest. It is classified into 5 groups based on etiology. Common mechanisms include vasoconstriction, vascular obstruction, increased blood flow, and loss of pulmonary vascular bed. Pathology often involves remodeling of small pulmonary arteries and arterioles. Presentation is usually nonspecific symptoms like dyspnea. Diagnosis involves echocardiogram, cardiac catheterization, and ruling out other causes. Treatment includes vasodilators, anticoagulation, diuretics, oxygen supplementation and sometimes
This document provides an overview of pulmonary hypertension (PH), including its classification, pathophysiology, clinical presentation, diagnostic evaluation, and treatment. PH is classified into 5 groups depending on its underlying cause. It results from increased pulmonary vascular resistance leading to right heart strain. Patients typically present with dyspnea and signs of right heart failure. Diagnosis requires right heart catheterization. Treatment focuses on supporting right ventricular function, optimizing volume status, decreasing afterload, and treating the underlying cause.
1. Pulmonary hypertension (PH) is defined as a mean pulmonary arterial pressure ≥ 25 mmHg at rest as assessed by right heart catheterization.
2. PH can be classified as pre-capillary or post-capillary based on pulmonary wedge pressure and pulmonary vascular resistance.
3. Treatment for PH targets three main pathways - nitric oxide-soluble guanylate cyclase-cGMP pathway, endothelin-1 pathway, and prostacyclin pathway. Medications include phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, prostacyclin analogs, and riociguat.
This presentation covers the methodology of evaluating CTEPH (chronic thromboembolic pulmonary hypertension) case. It starts from the basic concepts of Pulmonary hypertension.
1) Pulmonary arterial hypertension (PAH) is defined as a mean pulmonary artery pressure over 25 mmHg at rest as determined by right heart catheterization along with a pulmonary vascular resistance over 3 Wood units.
2) The diagnosis of PAH requires excluding other causes of pulmonary hypertension such as left heart disease, lung disease, chronic thromboembolic pulmonary hypertension, and other rare diseases.
3) PAH results from an imbalance of vasoactive and growth factors causing remodeling of the pulmonary arteries which increases pulmonary vascular resistance and mean pulmonary artery pressure over time.
4) Treatment involves general measures to avoid worsening along with medical therapies targeting vasoactive pathways and newer PAH specific drug classes, with lung transplantation as a
Pulmonary hypertension is abnormal elevation of pulmonary artery pressure that can be caused by several factors. It occurs when the arteries in the lungs become narrowed, blocking blood flow and overworking the heart. There are five groups of pulmonary hypertension distinguished by their causes, which include left heart disease, lung diseases that cause hypoxia, chronic thromboembolic pulmonary hypertension, rare diseases with unclear causes, and pulmonary arterial hypertension. The latter involves thickening of pulmonary arteries and is the most severe form, sometimes caused by genetic mutations. Symptoms include shortness of breath and right heart failure over time if left untreated.
1) The document discusses the updated classification of pulmonary hypertension and outlines the diagnostic and management approach.
2) It reviews the criteria for diagnosing pulmonary hypertension based on mean pulmonary artery pressure and outlines potential causes.
3) The key objectives are to review the updated WHO classification of pulmonary hypertension, diagnostic testing approaches including echocardiography and right heart catheterization, and clinical management based on disease severity including medication options and monitoring response to therapy.
This document provides an overview of pulmonary hypertension (PH), including its history, clinical findings, investigations, classification, pathophysiology, and management. Some key points:
- PH can be caused by various underlying conditions and diseases. A thorough workup is needed to determine the specific type and cause.
- Common presenting symptoms are dyspnea and fatigue. Physical exam may reveal signs of right heart failure as disease progresses.
- Initial screening tests include echocardiogram, ECG, CXR. Right heart catheterization is the gold standard for diagnosis and assessing severity.
- PH is classified into 5 types based on underlying pathophysiology. The main types are PAH, PH related to lung/
Pulmonary Arterial Hypertension Overview
Michael J. Cuttica MD Assistant Professor of Medicine Northwestern Pulmonary Hypertension Program
Northwestern University
Pulmonary arterial hypertension (PAH) is high blood pressure in the pulmonary arteries of the lungs. It can be caused by various conditions and is diagnosed through tests like echocardiograms, pulmonary function tests, and right heart catheterization. As PAH progresses, the increased pressure in the lungs puts strain on the right side of the heart. Treatment aims to relieve symptoms and slow disease progression through oral medications, inhaled treatments, IV therapies, and possibly lung transplantation in severe cases.
Pulmonary Arterial Hypertension: The Other High Blood Pressure and its association with scleroderma is presented by
Micheal J. Cuttica MD, MS, Assistant Professor of Medicine, Director; Northwestern Pulmonary Hypertension Program, Northwestern University
This document summarizes pulmonary vascular lesions and pulmonary hypertension. It discusses the anatomy of the pulmonary vasculature and provides a histological classification of pulmonary vascular lesions. It also covers pulmonary hypertension, describing definitions, clinical features, investigations including right heart catheterization, and management strategies such as supportive therapy, advanced drug therapies, atrial septostomy, and lung transplantation.
This document discusses pulmonary vascular lesions and pulmonary hypertension. It begins with an overview of pulmonary vascular anatomy and classifications of pulmonary hypertension and vascular lesions. It then covers topics like the pathogenesis of pulmonary hypertension, clinical presentation, investigations including echocardiography and right heart catheterization, and management strategies. In particular, it focuses on current and emerging drug therapies for pulmonary arterial hypertension including endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostanoids.
Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure ≥25 mmHg at rest. It is characterized by elevated pulmonary pressures and secondary right ventricular failure. PH can be caused by genetic mutations, pulmonary arterial hypertension (PAH) second hits like congenital heart disease or HIV, or pulmonary venous hypertension second hits like COPD or heart failure. Symptoms include dyspnea, chest pain, syncope, and edema. Diagnostic testing includes echocardiogram, right heart catheterization, and blood tests. Treatment involves diuretics, oxygen, anticoagulation, and advanced therapies for PAH like vasodilators or lung transplantation.
1) The patient presented with exertional dyspnea and was found to have a pulmonary artery systolic pressure of 80 mm Hg and right ventricular enlargement on echocardiogram.
2) Further tests including right heart catheterization confirmed the diagnosis of pulmonary arterial hypertension with a mean pulmonary artery pressure of 52 mm Hg.
3) Treatment for this patient's World Health Organization functional class III pulmonary arterial hypertension will include oxygen supplementation, diuretics, anticoagulation, and advanced vasodilatory therapy targeting the underlying cause and cardiovascular effects.
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of at least 25 mm Hg. It can be caused by various conditions and is classified accordingly. Idiopathic pulmonary hypertension has no known cause. It presents with dyspnea and right heart failure. Diagnosis involves right heart catheterization showing elevated pulmonary pressures. Treatment includes diuretics, vasodilators like calcium channel blockers, endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and sometimes atrial septostomy or lung transplantation for severe cases refractory to medical therapy. Prognosis depends on factors like functional status, hemodynamics, and response to treatment.
- Pulmonary artery hypertension (PAH) is defined as a mean pulmonary artery pressure of ≥25 mmHg at rest. It is characterized by pre-capillary pulmonary hypertension with a pulmonary wedge pressure <15 mmHg and a pulmonary vascular resistance >3 Wood units.
- The pathophysiology involves sustained vasoconstriction, vascular remodeling, in situ thrombosis, and increased arterial stiffness. Genetic factors like BMPR2 mutations also contribute to PAH development.
- Clinical features range from mild breathlessness to signs of right heart failure. Diagnostic tests include echocardiography, CT scans, V/Q scans, right heart catheterization and lab tests.
- Treatment involves oxygen therapy, diure
Pulmonary hypertension is defined as a mean pulmonary artery pressure greater than 25 mmHg. It is classified based on whether the elevation in pressure is pre-capillary or post-capillary. The pathogenesis involves various changes in the pulmonary vasculature that lead to increased pulmonary vascular resistance. Diagnosis involves symptoms, physical exam findings, imaging like echocardiogram, and right heart catheterization. Treatment aims to improve hemodynamics and symptoms through pulmonary vasodilators and diuretics. Anesthetic management of pulmonary hypertension patients requires optimizing preload, afterload, and contractility while avoiding triggers of pulmonary hypertension. Close monitoring is important both intraoperatively and postoperatively.
This document summarizes pulmonary hypertension and its management. It discusses the pulmonary circulation and pressures, types and classification of pulmonary hypertension, pathogenesis involving various molecular pathways, clinical diagnosis using echocardiography, right heart catheterization, and treatment goals and strategies. The main treatment approaches discussed are calcium channel blockers, prostanoids, endothelin receptor antagonists, phosphodiesterase inhibitors, and soluble guanylate cyclase stimulators. The goals of treatment are to palliate symptoms, improve exercise tolerance and right ventricular function, and strive to improve survival rates.
The document discusses pulmonary hypertension (PH) due to lung disorders. It defines PH and classifies it based on its underlying causes. PH due to lung diseases and hypoxia (group 3 PH) is associated with obstructive lung diseases like COPD, restrictive lung diseases, mixed lung diseases, and hypoxia without lung disease. Symptoms include dyspnea, fatigue, and signs of right heart failure as PH progresses. Imaging like echocardiogram and right heart catheterization are used to diagnose and assess severity of PH. Treatment involves managing the underlying lung condition, supportive therapies, and in severe cases, pulmonary arterial hypertension therapies may be considered though data is limited in group 3 PH. Prognosis is typically progressive with increased mortality
Heart failure is a clinical syndrome where the heart is unable to pump enough blood to meet the body's needs. It can be caused by conditions that reduce the heart's ability to contract or fill properly and common symptoms include dyspnea, fatigue, and edema. Upon presentation, patients exhibiting signs of congestion such as elevated jugular pressure, rales, and edema are treated with diuretics, while those with low blood pressure or organ dysfunction may require inotropic support or mechanical circulatory support.
Management of Pulmonary Hypertension in Critical Care Settings.pptxSami Rehman
This document provides an overview of pulmonary hypertension (PH), including its definition, grading system, clinical presentation, diagnostic workup and tests, assessment of severity and risk, pathophysiology, treatment and management, especially in ICU settings. PH is defined as a mean pulmonary arterial pressure greater than 20 mm Hg at rest or 30 mm Hg with exercise, often leading to progressive right ventricular failure. It is classified into 5 groups by the WHO based on pathophysiology and treatment. The diagnostic workup involves blood tests, imaging like echocardiogram, right heart catheterization, and tests like PFTs and CT scans. Treatment focuses on pulmonary vasodilators, diuretics, oxygen therapy, and possibly mechanical circulatory support
Pathophysiology of pulmonary hypertensionsoumyasil
This document discusses the pathophysiology of pulmonary hypertension. It begins with the anatomy of the pulmonary vasculature and haemodynamics of normal pulmonary circulation. It then covers the classification of pulmonary hypertension by the WHO, focusing on Group 1 which includes pulmonary arterial hypertension. Causes of PAH like idiopathic PAH, heritable PAH, drug-induced PAH, and PAH associated with other conditions are explained. Other groups of pulmonary hypertension related to left heart disease, lung disorders, chronic thromboembolic pulmonary hypertension, and miscellaneous conditions are also summarized.
Pulmonary hypertension (PH) is defined as a mean pulmonary arterial pressure > 25 mmHg. It is classified into 5 groups, including pulmonary arterial hypertension (PAH), PH due to left heart disease, PH due to lung diseases/hypoxia, chronic thromboembolic PH, and PH with unclear mechanisms. Clinical symptoms include dyspnea, fatigue, chest pain, syncope, edema, and cough. Diagnostic tests involve echocardiogram, chest X-ray, ECG, and right heart catheterization. Management includes supportive therapies, calcium channel blockers, endothelin receptor antagonists, phosphodiesterase inhibitors, prostacyclins, and transplantation.
PREGNANCY AND PHYSIOLOGICAL CHANGES.pptxAshraf Shaik
During pregnancy, the female body undergoes many physiological changes to support the growing fetus. The genital organs like the uterus, cervix, and breasts enlarge and the vascularity increases. The uterus grows enormously and its shape changes from globular to spherical. Other changes include increased blood volume and cardiac output, skin and cutaneous changes, weight gain, respiratory alkalosis, and hormonal changes mediated by the placenta and pituitary gland. These changes help provide nutrients and oxygen to the developing fetus and prepare the body for childbirth.
This document provides information on diagnosing pregnancy through various stages. In the first trimester, signs may include missed period, morning sickness, frequent urination, and breast changes. HCG levels can be detected in blood and urine from 8-11 days after conception. Ultrasound can visualize the gestational sac from 4-5 weeks. In the second trimester, signs include quickening, abdominal growth, and fetal movement felt externally from 20 weeks. Anatomy scan at 18-20 weeks evaluates fetal development. In the third trimester, signs include increased size, lightening, and engagement of the presenting part. Fundal height corresponds to weeks until 36 weeks. Differential diagnosis includes conditions that cause abdominal swelling.
1) Pulmonary arterial hypertension (PAH) is defined as a mean pulmonary artery pressure over 25 mmHg at rest as determined by right heart catheterization along with a pulmonary vascular resistance over 3 Wood units.
2) The diagnosis of PAH requires excluding other causes of pulmonary hypertension such as left heart disease, lung disease, chronic thromboembolic pulmonary hypertension, and other rare diseases.
3) PAH results from an imbalance of vasoactive and growth factors causing remodeling of the pulmonary arteries which increases pulmonary vascular resistance and mean pulmonary artery pressure over time.
4) Treatment involves general measures to avoid worsening along with medical therapies targeting vasoactive pathways and newer PAH specific drug classes, with lung transplantation as a
Pulmonary hypertension is abnormal elevation of pulmonary artery pressure that can be caused by several factors. It occurs when the arteries in the lungs become narrowed, blocking blood flow and overworking the heart. There are five groups of pulmonary hypertension distinguished by their causes, which include left heart disease, lung diseases that cause hypoxia, chronic thromboembolic pulmonary hypertension, rare diseases with unclear causes, and pulmonary arterial hypertension. The latter involves thickening of pulmonary arteries and is the most severe form, sometimes caused by genetic mutations. Symptoms include shortness of breath and right heart failure over time if left untreated.
1) The document discusses the updated classification of pulmonary hypertension and outlines the diagnostic and management approach.
2) It reviews the criteria for diagnosing pulmonary hypertension based on mean pulmonary artery pressure and outlines potential causes.
3) The key objectives are to review the updated WHO classification of pulmonary hypertension, diagnostic testing approaches including echocardiography and right heart catheterization, and clinical management based on disease severity including medication options and monitoring response to therapy.
This document provides an overview of pulmonary hypertension (PH), including its history, clinical findings, investigations, classification, pathophysiology, and management. Some key points:
- PH can be caused by various underlying conditions and diseases. A thorough workup is needed to determine the specific type and cause.
- Common presenting symptoms are dyspnea and fatigue. Physical exam may reveal signs of right heart failure as disease progresses.
- Initial screening tests include echocardiogram, ECG, CXR. Right heart catheterization is the gold standard for diagnosis and assessing severity.
- PH is classified into 5 types based on underlying pathophysiology. The main types are PAH, PH related to lung/
Pulmonary Arterial Hypertension Overview
Michael J. Cuttica MD Assistant Professor of Medicine Northwestern Pulmonary Hypertension Program
Northwestern University
Pulmonary arterial hypertension (PAH) is high blood pressure in the pulmonary arteries of the lungs. It can be caused by various conditions and is diagnosed through tests like echocardiograms, pulmonary function tests, and right heart catheterization. As PAH progresses, the increased pressure in the lungs puts strain on the right side of the heart. Treatment aims to relieve symptoms and slow disease progression through oral medications, inhaled treatments, IV therapies, and possibly lung transplantation in severe cases.
Pulmonary Arterial Hypertension: The Other High Blood Pressure and its association with scleroderma is presented by
Micheal J. Cuttica MD, MS, Assistant Professor of Medicine, Director; Northwestern Pulmonary Hypertension Program, Northwestern University
This document summarizes pulmonary vascular lesions and pulmonary hypertension. It discusses the anatomy of the pulmonary vasculature and provides a histological classification of pulmonary vascular lesions. It also covers pulmonary hypertension, describing definitions, clinical features, investigations including right heart catheterization, and management strategies such as supportive therapy, advanced drug therapies, atrial septostomy, and lung transplantation.
This document discusses pulmonary vascular lesions and pulmonary hypertension. It begins with an overview of pulmonary vascular anatomy and classifications of pulmonary hypertension and vascular lesions. It then covers topics like the pathogenesis of pulmonary hypertension, clinical presentation, investigations including echocardiography and right heart catheterization, and management strategies. In particular, it focuses on current and emerging drug therapies for pulmonary arterial hypertension including endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostanoids.
Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure ≥25 mmHg at rest. It is characterized by elevated pulmonary pressures and secondary right ventricular failure. PH can be caused by genetic mutations, pulmonary arterial hypertension (PAH) second hits like congenital heart disease or HIV, or pulmonary venous hypertension second hits like COPD or heart failure. Symptoms include dyspnea, chest pain, syncope, and edema. Diagnostic testing includes echocardiogram, right heart catheterization, and blood tests. Treatment involves diuretics, oxygen, anticoagulation, and advanced therapies for PAH like vasodilators or lung transplantation.
1) The patient presented with exertional dyspnea and was found to have a pulmonary artery systolic pressure of 80 mm Hg and right ventricular enlargement on echocardiogram.
2) Further tests including right heart catheterization confirmed the diagnosis of pulmonary arterial hypertension with a mean pulmonary artery pressure of 52 mm Hg.
3) Treatment for this patient's World Health Organization functional class III pulmonary arterial hypertension will include oxygen supplementation, diuretics, anticoagulation, and advanced vasodilatory therapy targeting the underlying cause and cardiovascular effects.
Pulmonary hypertension is defined as a mean pulmonary arterial pressure of at least 25 mm Hg. It can be caused by various conditions and is classified accordingly. Idiopathic pulmonary hypertension has no known cause. It presents with dyspnea and right heart failure. Diagnosis involves right heart catheterization showing elevated pulmonary pressures. Treatment includes diuretics, vasodilators like calcium channel blockers, endothelin receptor antagonists, phosphodiesterase inhibitors, prostanoids, and sometimes atrial septostomy or lung transplantation for severe cases refractory to medical therapy. Prognosis depends on factors like functional status, hemodynamics, and response to treatment.
- Pulmonary artery hypertension (PAH) is defined as a mean pulmonary artery pressure of ≥25 mmHg at rest. It is characterized by pre-capillary pulmonary hypertension with a pulmonary wedge pressure <15 mmHg and a pulmonary vascular resistance >3 Wood units.
- The pathophysiology involves sustained vasoconstriction, vascular remodeling, in situ thrombosis, and increased arterial stiffness. Genetic factors like BMPR2 mutations also contribute to PAH development.
- Clinical features range from mild breathlessness to signs of right heart failure. Diagnostic tests include echocardiography, CT scans, V/Q scans, right heart catheterization and lab tests.
- Treatment involves oxygen therapy, diure
Pulmonary hypertension is defined as a mean pulmonary artery pressure greater than 25 mmHg. It is classified based on whether the elevation in pressure is pre-capillary or post-capillary. The pathogenesis involves various changes in the pulmonary vasculature that lead to increased pulmonary vascular resistance. Diagnosis involves symptoms, physical exam findings, imaging like echocardiogram, and right heart catheterization. Treatment aims to improve hemodynamics and symptoms through pulmonary vasodilators and diuretics. Anesthetic management of pulmonary hypertension patients requires optimizing preload, afterload, and contractility while avoiding triggers of pulmonary hypertension. Close monitoring is important both intraoperatively and postoperatively.
This document summarizes pulmonary hypertension and its management. It discusses the pulmonary circulation and pressures, types and classification of pulmonary hypertension, pathogenesis involving various molecular pathways, clinical diagnosis using echocardiography, right heart catheterization, and treatment goals and strategies. The main treatment approaches discussed are calcium channel blockers, prostanoids, endothelin receptor antagonists, phosphodiesterase inhibitors, and soluble guanylate cyclase stimulators. The goals of treatment are to palliate symptoms, improve exercise tolerance and right ventricular function, and strive to improve survival rates.
The document discusses pulmonary hypertension (PH) due to lung disorders. It defines PH and classifies it based on its underlying causes. PH due to lung diseases and hypoxia (group 3 PH) is associated with obstructive lung diseases like COPD, restrictive lung diseases, mixed lung diseases, and hypoxia without lung disease. Symptoms include dyspnea, fatigue, and signs of right heart failure as PH progresses. Imaging like echocardiogram and right heart catheterization are used to diagnose and assess severity of PH. Treatment involves managing the underlying lung condition, supportive therapies, and in severe cases, pulmonary arterial hypertension therapies may be considered though data is limited in group 3 PH. Prognosis is typically progressive with increased mortality
Heart failure is a clinical syndrome where the heart is unable to pump enough blood to meet the body's needs. It can be caused by conditions that reduce the heart's ability to contract or fill properly and common symptoms include dyspnea, fatigue, and edema. Upon presentation, patients exhibiting signs of congestion such as elevated jugular pressure, rales, and edema are treated with diuretics, while those with low blood pressure or organ dysfunction may require inotropic support or mechanical circulatory support.
Management of Pulmonary Hypertension in Critical Care Settings.pptxSami Rehman
This document provides an overview of pulmonary hypertension (PH), including its definition, grading system, clinical presentation, diagnostic workup and tests, assessment of severity and risk, pathophysiology, treatment and management, especially in ICU settings. PH is defined as a mean pulmonary arterial pressure greater than 20 mm Hg at rest or 30 mm Hg with exercise, often leading to progressive right ventricular failure. It is classified into 5 groups by the WHO based on pathophysiology and treatment. The diagnostic workup involves blood tests, imaging like echocardiogram, right heart catheterization, and tests like PFTs and CT scans. Treatment focuses on pulmonary vasodilators, diuretics, oxygen therapy, and possibly mechanical circulatory support
Pathophysiology of pulmonary hypertensionsoumyasil
This document discusses the pathophysiology of pulmonary hypertension. It begins with the anatomy of the pulmonary vasculature and haemodynamics of normal pulmonary circulation. It then covers the classification of pulmonary hypertension by the WHO, focusing on Group 1 which includes pulmonary arterial hypertension. Causes of PAH like idiopathic PAH, heritable PAH, drug-induced PAH, and PAH associated with other conditions are explained. Other groups of pulmonary hypertension related to left heart disease, lung disorders, chronic thromboembolic pulmonary hypertension, and miscellaneous conditions are also summarized.
Pulmonary hypertension (PH) is defined as a mean pulmonary arterial pressure > 25 mmHg. It is classified into 5 groups, including pulmonary arterial hypertension (PAH), PH due to left heart disease, PH due to lung diseases/hypoxia, chronic thromboembolic PH, and PH with unclear mechanisms. Clinical symptoms include dyspnea, fatigue, chest pain, syncope, edema, and cough. Diagnostic tests involve echocardiogram, chest X-ray, ECG, and right heart catheterization. Management includes supportive therapies, calcium channel blockers, endothelin receptor antagonists, phosphodiesterase inhibitors, prostacyclins, and transplantation.
PREGNANCY AND PHYSIOLOGICAL CHANGES.pptxAshraf Shaik
During pregnancy, the female body undergoes many physiological changes to support the growing fetus. The genital organs like the uterus, cervix, and breasts enlarge and the vascularity increases. The uterus grows enormously and its shape changes from globular to spherical. Other changes include increased blood volume and cardiac output, skin and cutaneous changes, weight gain, respiratory alkalosis, and hormonal changes mediated by the placenta and pituitary gland. These changes help provide nutrients and oxygen to the developing fetus and prepare the body for childbirth.
This document provides information on diagnosing pregnancy through various stages. In the first trimester, signs may include missed period, morning sickness, frequent urination, and breast changes. HCG levels can be detected in blood and urine from 8-11 days after conception. Ultrasound can visualize the gestational sac from 4-5 weeks. In the second trimester, signs include quickening, abdominal growth, and fetal movement felt externally from 20 weeks. Anatomy scan at 18-20 weeks evaluates fetal development. In the third trimester, signs include increased size, lightening, and engagement of the presenting part. Fundal height corresponds to weeks until 36 weeks. Differential diagnosis includes conditions that cause abdominal swelling.
1. An episiotomy is a surgically planned incision made in the perineum during the second stage of labor to enlarge the vaginal opening and facilitate delivery while minimizing perineal tearing.
2. It is most commonly done for primigravid women, those with a rigid perineum, or those requiring forceps delivery or breech birth.
3. The incision is usually mediolateral, extending from the midline outwards, and is repaired in three layers after delivery to restore anatomy and function.
The document describes various obstetric instruments and their uses:
- Simple rubber catheters are used to empty the bladder during pregnancy, labor, and postpartum. Foley catheters provide continuous bladder drainage in cases like eclampsia.
- Sims' speculum and Cusco's speculum are used to inspect the cervix and vagina. Forceps like Allis tissue forceps gently hold tissues during procedures.
- Dilators like Hawkin-Ambler and Hegar's dilators are used to widen the cervical canal before evacuation procedures. Ovum forceps and uterine curettes remove products of conception.
- Vacuum aspiration cannulas of various sizes are
This document discusses obstructed labor and prolonged labor. Obstructed labor is defined as labor where there is poor or no progress despite uterine contractions, and is caused by issues with the pelvis, fetus, or other maternal conditions. Prolonged labor is labor lasting over 18 hours. Both can cause maternal and fetal complications like rupture, infection, asphyxia, and death if not properly managed. Management involves general supportive care, monitoring labor progress, and obstetric interventions like medications, instrumental delivery, or c-section depending on the stage of labor and specific issues present.
This document discusses paraneoplastic syndromes, which are clinical disorders associated with but not directly caused by malignant tumors. It provides examples of various paraneoplastic syndromes involving the endocrine system, hematologic system, skin, kidneys, lungs and other organs. It also discusses neurological manifestations such as opsoclonus-myoclonus syndrome, limbic encephalitis, cerebellar degeneration and others. Evaluation and treatment of the underlying malignancy is important for managing paraneoplastic syndromes.
Lung abscess is defined as necrosis of pulmonary tissue and formation of cavities containing necrotic debris or fluid, usually caused by microbial infection. It commonly results from aspiration of oropharyngeal contents colonized with anaerobic bacteria. Patients often present with nonspecific symptoms like fever, cough, sputum production, and weight loss. Physical exam may reveal consolidation and signs of any associated pleural effusions or pneumothoraces. Treatment involves prolonged antibiotic therapy, though surgery was historically used. Failure to treat lung abscess is associated with poor clinical outcomes.
The document discusses physiology and management of the normal postpartum period (puerperium). It defines puerperium as the 6-week period following childbirth when the body returns to a non-pregnant state. The puerperium involves involution of the uterus and other reproductive organs. It describes the stages of puerperium and changes that occur in the uterus, cervix, vagina, breasts and other organs during this period. Key signs like lochia, after pains, constipation and breast changes are also summarized.
This document provides information on uterovaginal prolapse including anatomy, supports of the uterus, types of prolapse, degree of uterine descent, aetiology, symptoms, clinical presentation, diagnostic approach, examination, complications, prevention, and management. The three main levels of uterine support are described as the upper, middle, and lower tiers. Genital prolapse is defined as the descent of one or more genital organs through the pelvic floor. The POPQ system is introduced for assessing prolapse. Childbirth is a primary risk factor for prolapse due to trauma, and prevention focuses on proper techniques during labor and repair of tears. Treatment includes pessaries, pelvic floor exercises, and various surgical procedures depending
The document discusses the Mantoux tuberculin skin test, which is used to detect infection with Mycobacterium tuberculosis. It describes how the test works, involving injecting a small amount of purified protein derivative (PPD) intradermally and checking for induration 48-72 hours later. Positive results typically show induration of 10mm or more, though interpretation depends on risk factors like BCG vaccination or exposure. Proper administration and reading of the test is important to avoid false negatives or positives.
This document discusses pulmonary thromboembolism (PE), which refers to blood clots (thrombi) traveling from deep veins to the lungs. Most clots originate in the lower extremities. Risk factors include inherited conditions, surgery, trauma, immobilization, cancer and pregnancy. PE can cause hypoxemia and pulmonary hypertension. Diagnosis involves clinical assessment, D-dimer testing, chest imaging like CT pulmonary angiogram (gold standard), ventilation-perfusion scanning and echocardiogram. Treatment aims to relieve symptoms and prevent complications like right heart strain.
Status asthmaticus is a severe exacerbation of asthma that is unresponsive to initial treatment. It involves both an early bronchospastic component and later inflammatory response leading to airway obstruction. Treatment goals are to reverse airway obstruction, correct hypoxemia, and prevent complications. Mainstay treatments include nebulized beta-2 agonists, systemic steroids, theophyllines, and mechanical ventilation if needed. Impulse oscillometry testing can objectively monitor response to treatment. With aggressive treatment, prognosis is generally good except when combined with other conditions.
Pulmonary tuberculosis is caused by infection with Mycobacterium tuberculosis, which is a small, aerobic bacillus. Symptoms include a prolonged cough lasting over 3 weeks, coughing up sputum or blood, fever, night sweats, and weight loss. Diagnosis involves chest x-ray, sputum smear and culture, and the Mantoux tuberculin skin test. Treatment requires a combination of antibiotics like isoniazid, rifampin, pyrazinamide, and ethambutol over a period of 6-9 months to prevent drug resistance from developing. Tuberculosis remains a major global health problem and India has a high burden of cases.
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- Diagnosis involves chest imaging, diagnostic thoracentesis and fluid analysis to determine if the fluid is an exudate or transudate based on pleural fluid to serum ratios of protein and LDH. Additional fluid tests provide clues to specific causes.
- Pleural fluid characteristics like glucose, pH and cell differentials provide diagnostic information and indicate need for drainage in some cases like parapneumonic effusions
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2. Table of Contents
• Definition
• Classification of PH
• Pathology & Pathophysiology
• Approach to diagnosis
• Treatment
• Follow-up.
3. Definition of PAH by WHO
• Increase in blood pressure in pulmonary
circulation ( either in the arteries, or both in
arteries and veins)
• Normal pressure is 14-18mmHg at rest.
• 20-25mmHg on exercise.
• Hemodynamically it is defined as an increase in
mean pulmonary arterial pressure to >-25mmHg at
rest.
• Can be measured by right heart catheterization.
4. ▪ Two definitions of PH that were previously
accepted are no longer used.
▪ Mean pulmonary artery pressure >30 mmHg with
exercise (measured by right heart catheterization)
▪ Estimated systolic pulmonary artery pressure >40
mmHg (estimated by Doppler echocardiography)
5. WHO Classifications of
Pulmonary Hypertension
1. Pulmonary Arterial Hypertension
2. Pulmonary Hypertension owing to left heart disease
3. PH Secondary to Chronic Hypoxemia
4. Chronic Thrombo-Embolic Pulmonary Hypertension
(CTEPH)
5. Miscellaneous (usually extrinsic compression of
pulmonary arteries)
WHO Venice 2003 – Later updated in 2008 (Dana point)
6. Epidemiology of PH
15%
11% 10% 9.50%
6%
4%
40% 39%
35%
30%
25%
20%
15%
10%
5%
0%
I diopathic Connective
Tissues
Disease
Congenital
Heart Disease
Portal HTN Appetite
Suppressant
HI V Familial
7. ▪ Obstructive sleep apnea
(OSA) – A review of
eight studies estimated
that the prevalence of
mild PH is 15 to 20 %
among patients with
OSA (Cardiovascular effects of
obstructive sleep apnea –up to date)
8. Group 1 - PAH
•
•
•
•
•
IPAH
Familial – BMPR2, ALK 1,Unknown
Associated with PAH
– Connective Tissue Disease (Scleroderma, SLE, MCTD, RA)
– Congenital Heart Disease
– Portal hypertension (5-7% of patients)
– HIV (0.5% of patients)
– Drugs/toxins (aminorex-, dexfenfluramine-, or fenfluramine-
containing products, cocaine, methamphetamine)
– Other:
hereditary hemorrhagic telangiectasia, hemoglobinopathies,
myeloproliferative disorders, splenectomy
Associated with venous/capillary involvement
– Pulmonary veno-occlusive disease (evidence of pulmonary vascular
congestion)
–Pulmonary capillary hemangiomatosis
Persistent PH of newborn.
9. • Group 2: Pulmonary hypertension due to left heart
disease
– Systolic dysfunction
– Diastolic dysfunction
– Valvular disease
• Group 3: Pulmonary hypertension associated with
lung disease and/or hypoxemia
– Chronic obstructive lung disease
– Interstitial lung disease
– Sleep-disordered breathing
– Alveolar hypoventilation disorders
– Chronic exposure to high altitude
– Developmental abnormalities
10. • Group 4: Pulmonary hypertension due to chronic
thrombotic and/or embolic disease
– Thromboembolic obstruction of proximal pulmonary
arteries
– Thromboembolic obstruction of distal pulmonary
arteries
• Group 5: Miscellaneous
– Sarcoidosis, histiocytosis X, lymphangiomyomatosis,
compression of pulmonary vessels (adenopathy, tumor,
fibrosing mediastinitis, thyroid disorders, glycogen
storage disease, Gaucher’s disease,
14. Pathophysiology & Pathology – Group 1
• Exact mechanism – unknown.
• Multifactorial.
1)Excessive vasoconstriction -abnormal function or
expression of potassium channels in the smooth muscle
cells .
2)Endothelial dysfunction leads to chronically impaired
production of vasodilator and Vasoconstrictors
(NO, prostacyclin, thromboxane A2 and endothelin-1)
15. 3) Reduced plasma levels of other vasodilator and
antiproliferative substances such as vasoactive
intestinal peptide
4) In the adventitia there is increased production of
extracellular matrix including collagen, elastin,
fibronectin. Inflammatory cells and platelets
(through the serotonin pathway)
5) Prothrombotic abnormalities have been
demonstrated in PAH patients, and thrombi are
present in both the small distal pulmonary arteries
and the proximal elastic pulmonary arteries
17. • Due to lt. heart diseases:
• Pulmonary venous hypertension-most common cause
• Usually due to left-sided heart disease (valvular,
coronary or myocardial), obstruction to blood flow
downstream from the pulmonary veins.
• Reversibility is variable, dependent on lesion.
Pathophysiology & Pathology – Group 2
18. , PH due to lung diseases and/or hypoxia:
Multiple
1) hypoxic vasoconstriction,
2) mechanical stress of hyperinflated lungs,
3) loss of capillaries – emphysema, fibrosis
4)inflammation, and toxic effects of cigarette smoke.
5)endothelium-derived vasoconstrictor–vasodilator imbalance.
Hypoxia induced pulmonary vasoconstriction and anatomical
destruction of the vascular bed due to high pulmonary resistance
and ultimately RV failure.
Pathophysiology & Pathology – Group 3
19.
20. • CTEPH: non-resolution of acute embolic masses which
later undergo fibrosis leading to mechanical
obstruction of pulmonary arteries is the most important
process.
Pathophysiology & Pathology – Group 4
21. • PH with unclear and/or multifactorial mechanisms.
Pathophysiology & Pathology – Group 5
23. Reasons to Suspect PAH
▪ Unexplained dyspnea despite
multiple diagnostic tests
▪ Typical symptoms (look for
Raynaud’s)
▪ Comorbid conditons:
▪ CREST, liver disease, HIV,
sickle cell, OSA
▪ Family history of PAH
▪ History of stimulant/anorexigen
use
24. Symptoms of PAH
• Dyspnea 60%
•
•
•
•
•
•
19%
13%
7%
5%
3%
2%
Fatigue
Near syncope/syncope
Chest pain
Palpitations
LE edema
Hoarseness of voice
(Ortners syndrome)
27. • Labs
– Autoimmune serologies
– Markers of liver synthetic function
– HIV serologies when dictated by history
28. CXR in PH
Large central
Pulmonary arteries
Right Ventricular
Hypertrophy
Rapid attenuation of
pulmonary vessels
Clear Lung Fields
29. ECG in PH
• 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
(P pulmonale) due to
right atrial
enlargement
30. • Echocardiogram
– 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
31. 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
32.
33. Right Heart Catheterization
•
•
– RA <6
– RV <30/6
– PA <30/12
– PCWP <12
Pulmonary Vascular Resistance
Cardiac Output by the Fick Equation
34. • Mean PAP pressure
– At rest: >25mmHg
– With exercise: >30mmHg
• Wedge Pressure: <15mmHg
• Pulmonary Vascular Resistance: > 240
dynes-cm-sec-5
35. • Must be excluded in every case of PAH
• Potentially surgically remediable
• V/Q scan is preferred screening test
• CT pulmonary angiography
Always Rule out CTEPH
36. Vasoreactivity Testing During RHC
• Inhaled Nitric Oxide (NO) is a preferential
pulmonary arterial vasodilator
• Positive if:
– Mean PAP decreases at least 10 mmHg and to a value less
than 40 mmHg
– Associated increased or unchanged cardiac output
– Minimally reduced or unchanged systemic blood pressure
• Only patients with Positive Vasoreactivity are given
treatment trials with Calcium Channel Blockers!
39. • Registry to
Evaluate Early
and Long-term
PAH Disease
Management
• REVEAL
Registry PAH
risk score
calculator.
Calculated risk
scores can range
from 0 (lowest
risk) to 22
(highest risk).
40. Poor prognostic factors
▪
▪
▪
▪
▪
▪
▪
▪
▪
Age >45 years
(WHO) functional class III or IV
Failure to improve to a lower WHO functional class during treatment
Echocardiographic findings of a pericardial effusion, large right atrial
size, elevated right atrial pressure, or septal shift during diastole
Decreased pulmonary arterial capacitance (ie, the stroke volume
divided by the pulmonary arterial pulse pressure)
Increased N-terminal pro-brain natriuretic peptide level (NT-pro-BNP)
Prolonged QRS duration
Hypocapnia
Comorbid conditions (eg, COPD, diabetes)
41. Who do we treat for PAH?
• Treatment is based on functional status
New York Heart Association Functional Classification
Class 1: No symptoms with ordinary physical activity.
Class 2: Symptoms with ordinary activity. Slight limitation
of activity.
Class 3: Symptoms with less than ordinary activity. Marked
limitation of activity.
Class 4: Symptoms with any activity or even at rest.
42.
43. How do we Treat Them?
• General measures:
– Avoid pregnancy
• Contraception imperative
• Maternal mortality 30%
– Immunizations for respiratory
illnesses
Influenza & pneumonia vaccinations
– Minimize valsalva maneuvers—
increase risk of syncope
• Cough, constipation, heavy lifting, etc
44. Classes of therapy
• MEDICAL
•
•
•
•
•
Diuretics
Anti coagulants (IPAH)
Digoxin
Oxygen
PAH specific therapy
• SURGICAL THERAPY
•
•
Atrial septostomy
Lung transplantation
45. Diuretics
• Principally to treat edema from right heart failure
• May need to combine classes
• -Thiazide and loop diuretics
• Careful to avoid too much pre-load reduction
• Patients often require large doses of diuretics
46. Anticoagulants
• Studies only show benefit in IPAH patients, based
on improved survival.
• Other PAH groups not as clear, use in them
considered expert opinion.
• Generally, keep INR 2.0-2.5.
• Thought to lessen in-situ thrombosis
47. Oxygen
• Formal assessment of nocturnal and
exertional oxygenation needs.
• Minimize added insult of hypoxic
vasoconstriction
• Keep oxygen saturation ≥90%
• May be impossible with large right to left
shunt
• Exclude nocturnal desaturation
• Overnight oximetry
• Rule out concomitant obstructive sleep
apnea and hypoventilation syndromes
50. Calcium Channel Blockers
• Use only when demonstrated vasoreactivity in RHC
(about 10% or less of patients)
• Diltiazem or nifedipine preferred.
• Titrate up to maximum tolerated dose.
• Systemic hypotension may prohibit use
• Only 50% of patients maintain response to CCB.
• Not in FC IV patients or severe right heart failure
51. Endothelin Receptor Antagonists
(ETRA)
• Targets relative excess of endothelin-1 by blocking
receptors on endothelium and vascular smooth muscle
• Bosentan, Ambrisentan, Sitaxentan, Macitentan
• Ambrisentan is ET-A selective.
• Both show improvement in 6MWD and time to clinical
worsening.
• Monthly transaminase monitoring required for both
• Annual cost is high
52. • Potential for serious liver injury (including very rare cases
of unexplained hepatic cirrhosis after prolonged
treatment)
• Oral dosing
• Initiate at 62.5 mg BID for first 4 weeks
• Increase to maintenance dose of 125 mg BID thereafter
• Initiation and maintenance dose of 62.5 mg BID
recommended for patients >12 years of age with body
weight >40kg
• No dose adjustment required in patients with renal
impairment
• No predetermined dose adjustments required for
concomitant warfarin administration.
53. Ambrisentan
• 5 or 10 mg once daily
• Much less risk of transaminase elevation (about
1%), but monthly monitoring still required
• No dose adjustment of warfarin needed.
55. Sildenafil
• Safety
– Side effects: headaches, epistaxis, and
hypotension (transient)
– Sudden hearing loss
– Drug interaction with nitrates
– FDA approved dose is 20 mg TID
– Tadalafil 40mg OD
– Vardenafil 5mg OD
57. Epoprostenol
• First PAH specific therapy available in the mid
1990’s
• Lack of acute vasodilator response does not
correlate well with epoprostenol
unresponsiveness.
• Very short half life = 2 minutes
• Delivered via continuous infusion
• Cost about $100,000/year
59. Treprostinil (Remodulin)
• Continuous subcutaneous
infusion or IV infusion
• Longer t1/2 = 4 hours
• Less risk of rapid fatal
deterioriation if infusion stops
60. Treprostinil
• Intravenous treprostinil
– Hemodynamic improvements and 6MWD
improvements
– No site pain
– Risk of catheter related bloodstream infection
and embolic phenomenon
– Recent concerns about increased gram-negative
bloodstream infections.
62. Iloprost
• Improvements in 6MW, functional class and
hemodynamics observed
Olschewski H et al. N Engl J Med 2002;347:322-29
• Safety and side effects
–Potential for increased hypotensive effect
with antihypertensives
–Increased risk of bleeding, especially with
co-administration of anticoagulants
– Flushing, increased cough, headache, insomnia
– Nausea, vomiting, flu-like syndrome
– Increased liver enzymes
63. Guanylate cyclase stimulant
•
•
•
•
•
Stimulators of the nitric oxide receptor.
Dual mode of action.
They increase the sensitivity of sGC to endogenous nitric
oxide (NO)
Directly stimulate the receptor to mimic the action of NO.
Riociguat is an oral sGC stimulant that has reported
benefit in patients with inoperable and persistent chronic
thromboembolic pulmonary hypertension (CTEPH;
64.
65.
66. Failure of Medical Therapy: Consider
Atrial Septostomy
• Improved left-sided filling
• Decreased right-sided
pressures
• May serve as bridge to
transplant
67. Failure of Medical Therapy: Indications for
Lung Transplant
• New York Heart Association (NYHA)
functional class III or IV
• Mean right atrial pressure >10 mmHg
• Mean pulmonary arterial pressure >50
mmHg
• Failure to improve functionally
despite medical therapy
• Rapidly progressive disease