Pulmonary hypertension (PH) and congestive heart failure (CHF) Peter Eriksson, MD, PhD GUCH center, Sahlgrenska University Hospital Dept of Medicine, Sahlgrenska Academy University of Gothenburg, Sweden
The association between PH and CHF Increase of pulmonary vascular resistence, (PVR) gives pressure load to right ventricle and preload depletion of left venricle Left heart disease can lead to PH due to increased filling pressure What about the combination?
The important difference between PH and PAH PH is defined only by a mpap> 25 mmhg Many possible causes, most common is left heart disease. PAH is specific, Pulmonary Arterial Hypertension= increased PVR idiopatic/familiar Associated with; systemic disease, congenital heart disease, HIV, medication
Hemodynamic definition of PH and PAH mpap 25 mmhg Pulmonary hypertension (PH) > 36 25 Pulmonary hypertension 25 15 10 + Normal = PAH 4 Galiè N et al. European Heart Journal 2009; 30, 2493 2537
Clinical Classification of Pulmonary Hypertension (PH) 1. Pulmonary arterial hypertension (PAH) 2. PH due to left heart disease 3. PH due to pulmonary disease/hypoxemia 4. PH due to chronic tromboembolic disease 5. PH due to unclear or multifactorial mechanism Galiè N et al. European Heart Journal 2009; 30, 2493 2537
PAH! Left heart disease CHF Valvular IHD etc..
Remodelling of vessels in PAH Normal vessel PAH Advanced PAH Farber HW et al. N Engl J Med 2004;351:1655-65 Badesch DB et al, CHEST 2004; 126:35S-62S
Echocardiography Normal PAH Pressure overload right heart Preload depleted left heart
Why is PAH suddenly such a hot topic? Poor prognosis, 50% mortality in 2.8 years after diagnosis Introduction of PAH-specific treatment prostanoids endothelinreceptor antagonists phosphodieseras type-5 inhibitors D Alonzo et al. Ann Internal Med 1991;115:343
Left heart CHF Valvular PH= advanced disease!!
Does symtoms indicate if your CHF patients have PH or not? No, dyspnea and fatigue!
Where does the patient fall in the spectrum of diseases that include both CHF and PH?
Normal PA-pressure mild PH definitive PH mmhg 120 110 100 90 80 70 60 50 40 30 20 10 0 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Vmax TI (m/s) Vmax TI 3,5 m/s spap 50 mmhg: definitive PH Vmax TI 2,8 3,4 m/s spap 36 50 mmhg: mild PH Vmax TI 2,7 m/s spap 35 mmhg: normal ESC Pocket Guidelines 2006 (page 9). Adapted from European Heart Journal 2004; 25; 2243-78
PH in proportion to the degree of CHF? Right and left heart catheterization!
early PAH 50 10 5 40 5 8
Advanced PAH (without right heart failure) 90 10 5 80 5 16
3 Terminal PAH with right heart failure 55 5 2.5 50 2.5 20
PH in CHF 30 25 2.5 5 2.5 2
Is there an opportunity to improve the CHF (eg lower the PCWP)? medication, surgery, electrophysiology, VAD, transplantation??
When PCWP is optimized, does the PH still represent a plausible target for treatment with PAH-specific therapies? Prostanoids FIRST, decreased survival Endothelin receptor Antagonists REACH-1, stopped for safety reasons, to high doses? ENABLE, 1600 pts, no improvement Phosphdiesterase Type-5 Inhibitors No large scale studies, a number of small studies suggesting it to be safe and effective
Conclusion key question: is PH in proportion to the degree of CHF? If significant PH, optimize CHF treatment! In individual cases consider cautiously PAH-specific treatment, always guided by heart catheterization.
Jo tjena, symtomen var ju till stor hjälp Anemi? -Hb Fetma? -BMI>30 Luftvägsinfektion? -kem lab + lungrtg KOL? - progressiv + spirometri Astma? -episodisk + låter Hjärtsvikt?-anamnes AMI, HT + blåsljud, EKG Lungembolism? -anamnes venös tromboemboli
Nehej, vad kan det då vara? Psykosomatiskt Fortfarande hjärtsvikt Interstitiell lungsjukdom / systemsjukdom Pulmonell hypertension (PH)
Hur ser fortsatt utredning ut? Hjärt-Lung röntgen Spirometri EKG/poximetri Ultraljud av hjärtat (ekokardiografi) Vänster hjärthalva Höger hjärthalva TI hastighet > 3.4 m/s = PH TI hastighet >2.7 m/s men < 3.4 m/s =gråzon
Nej, det var det inte! Bra vänsterkammare, inga klaffel Diskrepans mellan funktionen av vänster hjärthalva och graden av pulmonell hypertension (PH) Lungscint (V/Q), CT thorax utesluta interstitiell lungsjukdom, kronisk lungembolism
? Lungsjukdom: Kron lungembolism Fibros KOL Hjärtsvikt Klaffel Behandla enligt diagnos!
Fortfarande oklart?
Varför hjärtkateterisering? Ohm s lag : U = R x I Gradienten = motståndet x flödet Mäta transpulmonell gradient (TPG) Lungartärtryck vänster förmakstryck (mmhg) Cardiac output (CO) (liter/minut) Motståndet (PVR)= TPG/CO Wood Units (WU)
Konklusion Skillnad på pulmonell hypertension (PH) och pulmonell arteriell hypertension (PAH) Viktigt med diagnos För diagnosen PAH krävs ALLTID hjärtkateterisering För initiering och uppföljning av behandling behövs ny hjärtkateterisering Bör skötas på dedikerade centra
Behandlingsalgoritm ESC / ERS 2009 Galiè N et al. European Heart Journal 2009; 30, 2493 2537
TI >3,4 m/s! OK, då är diagnosen PH! NEJ, PH är ingen diagnos men om du bedömer att den pulmonella hypertensionen förklaras av; - sviktande vänsterkammare som kräver höga fyllnadstryck - klaffvitier som mitralstenos/insufficiens, aortastenos Handlägges då enligt diagnosen