A rare, frequently fatal disease, most commonly seen in women, that is best managed in centres with expertise in pulmonary hypertension.
Presenting symptoms and signs are non-specific and include dyspnoea on exertion, fatigue, and a loud pulmonary component of the second heart sound.
Diagnosis of exclusion. Transthoracic Doppler echocardiography and right heart catheterisation can diagnose pulmonary hypertension. Laboratory tests and imaging studies can rule out known causes of pulmonary hypertension.
General supportive therapy includes oral anticoagulants, diuretics, supplemental oxygen, and digoxin.
Targeted treatment options include parenteral, inhaled, and oral prostanoids, oral endothelin receptor antagonists, oral phosphodiesterase type-5 inhibitors, the soluble guanylate cyclase stimulator riociguat, and the selective prostacyclin IP receptor agonist selexipag.
Prognosis is not good, as most patients eventually develop right ventricular failure.
Idiopathic pulmonary arterial hypertension (IPAH) is a disease of the small pulmonary arteries characterised by vascular proliferation and remodelling. It results in a progressive increase in pulmonary vascular resistance (PVR) and, ultimately, right ventricular failure and death. It is defined by a mean pulmonary arterial pressure ≥25 mmHg at rest with pulmonary capillary wedge pressure ≤15 mmHg and PVR >3 Woods units, without a known cause.
History and exam
Key diagnostic factors
- age 20 to 50 years
- female sex
- accentuated pulmonic component (P2) to the second heart sound
- tricuspid regurgitation murmur
- family history
Other diagnostic factors
- peripheral oedema
- stimulant use
- chest pain
- near syncope
- early diastolic, high-pitched murmur in the pulmonary area
- jugular vein distension
- family history
- female sex
- bone morphogenetic protein receptor type 2 (BMPR2) mutations
- appetite suppressants
- drugs and toxins
1st investigations to order
- transthoracic Doppler echocardiography
- right heart catheterisation
- nocturnal oximetry
- ventilation-perfusion (V/Q) scintigraphy
- 6-minute walk test
- B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP)
- full blood count
- thyroid function tests
- HIV serology
Investigations to consider
- high-resolution chest CT scan ± CT pulmonary angiography
- vasodilator testing with inhaled nitric oxide, intravenous epoprostenol, or intravenous adenosine
positive response to acute vasoreactivity testing with no contraindication to calcium-channel blockers
negative response to acute vasoreactivity testing or calcium-channel blockers contraindicated
- Pulmonary arterial hypertension (PAH) associated with left heart diseases (pulmonary venous hypertension)
- PAH associated with lung respiratory diseases and/or hypoxia
- PAH due to chronic thrombotic and/or embolic disease
- Guidelines for the diagnosis and treatment of pulmonary hypertension
- Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report
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