New guidance on managing pulmonary hypertension in the community

Considerable delays in diagnosis and treatment of pulmonary hypertension are having a ‘tremendous’ psychological, emotional, and social impact on patients and their families, according to new guidance announced at the European Society of Cardiology (ESC) Congress.

Pulmonary hypertension is high blood pressure in the lung circulation and affects almost 10% of individuals over 65 years of age. It is a severe condition associated with substantially reduced life expectancy, if not successfully treated.

The guidelines from the ESC and European Respiratory Society (ERS) recommend earlier detection of pulmonary hypertension in the community and expedited referral of high-risk or complex patients.

Patients with shortness of breath should seek medical help

Professor Stephan Rosenkranz of University Hospital Cologne, Germany, said: “In older patients, co-existing conditions (such as hypertension, obesity, or cardiopulmonary diseases) may be blamed for the symptoms and pulmonary hypertension is missed. Patients with shortness of breath should seek medical help, and if the GP, cardiologist or pulmonologist cannot identify an appropriate reason, referral to an expert pulmonary hypertension centre is indicated.”

Pulmonary hypertension is divided into five main groups based on the cause: 1) PAH, which is a distinct pulmonary vascular disease; 2) pulmonary hypertension associated with left heart disease; 3) pulmonary hypertension associated with chronic lung disease; 4) chronic thromboembolic pulmonary hypertension (CTEPH) due to recurrent blood clots in the lungs; and 5) pulmonary hypertension with unclear and/or multifactorial causes.

The guidelines cover the whole spectrum of pulmonary hypertension with an emphasis on diagnosing and treating PAH and CTEPH. For PAH, early diagnosis and initiation of treatment are key. Treatment options have improved within the last 15 years and three drug classes are currently approved. Most patients should receive a combination of at least two medications.

Treatment decisions should be guided by the risk assessment strategy outlined in the document. There are three options for treating CTEPH, which may be used alone or in combination. Pulmonary endarterectomy is the surgical removal of thromboembolic lesions from the pulmonary arteries and is the preferred strategy in eligible patients.

Balloon pulmonary angioplasty is indicated in some patients unsuitable for surgery or who have persistent or recurrent pulmonary hypertension after surgery. During this procedure, a balloon is temporarily inserted into the pulmonary arteries using a catheter then inflated to move thromboembolic lesions and restore blood flow.

The third treatment option is medication. Individual treatment strategies should be discussed in high volume centers with multidisciplinary teams.

Multidisciplinary input is central to the management of pulmonary hypertension. This is because a number of conditions can cause pulmonary hypertension, with left heart disease and chronic lung disease being the most frequent underlying causes.