Pulmonary hypertension due to left heart diseases

Abstract

Pulmonary hypertension (PH), a common complication of left heart diseases (LHD), negatively impacts symptoms, exercise capacity, and outcome. Although the true prevalence of PH-LHD is unknown, a subset of patients might present significant PH that cannot be explained by a passive increase in left-sided filling pressures. The term "out-of-proportion" PH has been used to identify that population without a clear definition, which has been found less than ideal and created confusion. We propose a change in terminology and a new definition of PH due to LHD. We suggest to abandon "out-of-proportion" PH and to distinguish "isolated post-capillary PH" from "post-capillary PH with a pre-capillary component" on the basis of the pressure difference between diastolic pulmonary artery pressure and pulmonary artery wedge pressure. Although there is no validated treatment for PH-LHD, we provide insights into management and discuss completed and randomized trials in this condition. Finally, we provide recommendations for future clinical trials to establish safety and efficacy of novel compounds to target this area of unmet medical need.

Keywords: CO; Cpc-PH; DPD; EF; HF; HF-pEF; LHD; LV; NO; PAH; PAWP; PCWP; PDE5; PH; PVD; PVR; RCT; RHC; RV; SV; TPG; VO(2); cardiac output; clinical trials; combined post-capillary and pre-capillary PH; diastolic pressure difference; ejection fraction; heart failure; heart failure with preserved ejection fraction; left heart disease; left ventricle/ventricular; mPAP; mean pulmonary artery pressure; nitric oxide; oxygen consumption; phosphodiesterase type 5; pulmonary arterial hypertension; pulmonary artery wedge pressure; pulmonary capillary wedge pressure; pulmonary hypertension; pulmonary vascular disease; pulmonary vascular resistance; randomized controlled trial; right heart catheterization; right ventricle; sGC; soluble guanylate cyclase; stroke volume; transpulmonary gradient.