Treatment for Pulmonary Hypertension of Left Heart Disease
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Pulmonary hypertension (PH) secondary to left heart disease is a largely underestimated target of therapy. Except for a specific focus on PH consequences in patients with advanced heart failure (HF) receiving a left ventricular mechanical assist device or candidates for transplantation, prevention and treatment of initial subclinical forms of PH are not considered a priority in the management of this chronic disease population. Nonetheless, there is recent growing evidence supporting a clinical and prognostic role of PH in the elderly and in HF with preserved ejection fraction (pEF). Studies have defined PH-HFpEF as a new entity typically defining the evolving nature of disease. Although the prevalence of PH in these populations is not well-defined, the potential for effective pharmacological approaches that might impact the natural history of the disease starting from earlier stages is promising. However, it should be recognized that pharmacological studies performed to date with traditional pulmonary vasodilators in cohorts with HF and left-sided PH have not been positive, primarily because of concomitant systemic hypotension and hepatic side effects. This evidence along with the lack of studies specifically performed in the elderly and HFpEF often lead Guidelines to give neutral recommendations or even arbitrary assumptions. Recent availability of selective well-tolerated pulmonary vasodilators, such as phosphodiesterase type 5 (PDE5) inhibitors, however, seem to offer a solid background for treating left-sided PH at both early and later stages of the disease process.
KeywordsPulmonary hypertension Heart failure Pulmonary vasodilators Prostaglandins Endothelin-1 receptor blockers Nitric oxide PDE-5 inhibitors Cardiac resynchronization therapy LV assist devices
This work was supported by a grant from the Monzino Foundation, Milano, Italy.
No potential conflicts of interest relevant to this article were reported.
References and Recommended Reading
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- 3.••Lam CS, Borlaug BA, Kane GC, Enders FT, Rodeheffer RJ, Redfield MM. Age-associated increases in pulmonary artery systolic pressure in the general population. Circulation. 2009;119:2663-70. This article provides data from the Olmsted County Study providing remarkable evidence for an age-related augmentation in pulmonary pressure that may provide prognostic insights in patients either with or without comorbid cardiopulmonary disease. PubMedCrossRefGoogle Scholar
- 4.••Lam CS, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, Redfield MM. Pulmonary hypertension in heart failure with preserved ejection fraction: a community-based study. J Am Coll Cardiol. 2009;53:1119-1126. This is a relevant study that defines how the cardiovascular risk of hypertensive patients with heart failure and preserved ejection fraction may be stratified according to a PASP cutoff of 48 mmHg estimated by echocardiography. PubMedCrossRefGoogle Scholar
- 5.Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, et al. ESC Committee for Practice Guidelines (CPG). Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009;30:2493–537.PubMedCrossRefGoogle Scholar
- 6.Serra W, Musiari L, Ardissino D, Gherli T, Montanari, A. Benefit of prostaglandin infusion in severe heart failure: Preliminary clinical experience of repetitive administration. Int. J. Cardiol. doi: 10.1016/j.ijcard.2008.12.173.
- 39.Guazzi M, Tumminello G, Di Marco F, Fiorentini C, Guazzi MD. The effects of phosphodiesterase-5 inhibition with sildenafil on pulmonary hemodynamics and diffusion capacity, exercise ventilatory efficiency, and oxygen uptake kinetics in chronic heart failure. J Am Coll Cardiol. 2004;44:2339–48.PubMedCrossRefGoogle Scholar
- 42.Hunt SA, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119:e391–479.PubMedCrossRefGoogle Scholar