Pulmonary Hypertension,Pulmonary Module Steven W. Harris MHS, PA-C,Pulmonary Hypertension,Defined as pressure within the pulmonary arterial system elevated above the normal range. greater than 25 mm Hg at rest or 30 mm Hg with exercise Pulmonary arterial pressure (PAP) usually 12-15 mmHg Left atrial pressure 6-10 mmHg,10/6/2018,2,Pulmonary hypertension develops when flow or resistance to flow across the pulmonary vascular bed increases,Four Categories of Pulmonary Hypertension Pulmonary hypertension from disorders of the respiratory system or hypoxemia. Pulmonary venous hypertension. Pulmonary hypertension from chronic thromboembolic disease. Pulmonary arterial hypertension. (PAH),10/6/2018,3,Chronic pulmonary hypertension is an important cause of right ventricular failure in the United States. Many of the individuals who die each year of chronic obstructive pulmonary disease (COPD) succumb secondarily to right ventricular failure resulting from pulmonary hypertension.,10/6/2018,4,In addition, greater than 200,000 deaths occur yearly from acute pulmonary embolism, the most common cause of sudden-onset pulmonary hypertension and acute right ventricular failure.,10/6/2018,5,10/6/2018,6,10/6/2018,7,10/6/2018,8,In persons more than 50 years of age, Cor pulmonale the consequence of untreated pulmonary hypertension, is the third most common cardiac disorder (after coronary and hypertensive heart disease).,10/6/2018,9,Entities that cause increased pulmonary blood flow,Congenital Heart Disease Left to right shunt “Hyperkinetic“ pulmonary hypertension can be seen in patients with congenital heart disease who have extensive left-to-right cardiac shunts that produce a large pulmonary blood flow Increased cardiac output states severe anemias,10/6/2018,10,Entities that cause an increased resistance to flow,Pulmonary embolism In situ pulmonary embolism Pulmonary fibrosis Sarcoidosis, scleroderma, or extensive pulmonary resection Severe COPD Thoracic deformities Large tumor or infiltrate,10/6/2018,11,Entities that cause changes in arterioles,Hypoxia (altitude) COPD Hypoventilation (sleep apnea) Acidosis Drugs Pulmonary arterial hypertension (PAH),10/6/2018,12,Entities that cause venous pressure changes & vascular resistance,Left atrial hypertension = Mitral Stenosis Left ventricular failure Pulmonary venous thrombosis Mediastinitis,10/6/2018,13,Pulmonary HTN,Elevated pulmonary venous pressure in the setting of left ventricular failure or mitral stenosis is associated with an immediate increase in pulmonary arterial pressure which maintains forward blood flow through the lungs despite the increase in pulmonary venous pressure.,10/6/2018,14,10/6/2018,15,Entities that increase blood viscosity,Polycythemia vera Leukemias with high WBCs,10/6/2018,16,Entities that increase intra-thoracic pressure,COPD Mechanical Ventilation: especially with PEEP,10/6/2018,17,Symptoms,Mild to moderate pulmonary hypertension are often asymptomatic More severe pulmonary hypertension usually complain of dyspnea on exertion secondary to exercise-induced decreases in cardiac output and increases in pulmonary arterial pressure.,10/6/2018,18,Symptoms,Easy fatigability, lethargy Exertional chest discomfort Syncope with exertion Cough Hemoptysis Hoarseness secondary to compression of the left recurrent laryngeal nerve by a dilated pulmonary artery(rare),10/6/2018,19,Physical Exam,Increased intensity of the pulmonic component of the second heart sound (P2) Systolic ejection murmur from tricuspid regurgAdvanced Disease Diastolic murmur of pulmonic regurgitation in patients with severe pulmonary hypertension Evidence of right ventricular dilatation (left parasternal lift or heave) A pulse prominent a wave in jugular venous system,10/6/2018,20,PE (contd),Signs of right ventricular failure: jugular venous distension Right ventricular S4 (increased loudness of the S4 on inspiration) Hepatomegaly Ascites, and/or peripheral edema,10/6/2018,21,Caveats,Patients with severe emphysema and increased thoracic anteroposterior diameter may not display the findings usually associated with advanced pulmonary hypertension because chest expansion make palpation and auscultation more difficult. The JVD may actually be above the jaw-line!,10/6/2018,22,Incidence of S & S,Loud P2 ( 80%) Right ventricular lift ( 80%) Dyspnea ( 75%) Murmur of tricuspid insufficiency (50-80%) Increased jugular venous pressure (50-80%) Right ventricular S4 (50-80%) Chest pain ( 50%) Fatigue ( 50%),10/6/2018,23,S & S contd,Palpitations ( 50%) Syncope; dizziness ( 50%) Cough ( 50%) Raynauds phenomenon ( 10%) Hepatomegaly ( 50%) Pulmonic ejection click ( 50%),10/6/2018,24,S & S contd,Right ventricular S3 ( 50%) Murmur of pulmonic insufficiency ( 50%) Lower extremity edema (males (1.7:1),