Day # 144 - Pulmonary Hypertension

Today we discussed a case of severe pulmonary hypertension presenting with shortness of breath and right heart failure.

There is a great review article on pulmonary hypertension here.

We initially discussed the physical exam findings in pulmonary hypertension:

JVP - Often elevated, may have CV waves if has tricuspid regurgitation, may have kussmaul's sign or abnormal abdominojugular reflux if RV failure

Palpation - RV lift/heave, epigastric heave, palpable second heart sound (P2), palpable RV S3 or S4, palpable thrill of TR

Auscultation - Loud second heart sound. May be widely split. Murmur of TR (LLSB radiating to epigastrium, apex or LUSB, holosystolic blowing murmur with respiratory increase (Carvallo's sign)). Right sided S3/S4

Abdominal Exam:

Ascites, pulsitile liver

Peripheral Exam:
Edema

We then discussed etiologies:

We then discussed the treatment options for pulmonary hypertension. This depends on the cause.

For group II, III, IV you need to try and treat the underlying problem (i.e. LV failure or MS/MR, chronic hypoxemia, sleep apnea)

The best evidence for treatment is in group I. But they are using these drugs for more and more conditions.

The options are:

Calcium channel blockers (don't really work)

Consider anticoagulation

• Phosphodiesterase inhibitors (like sildenafil)
• Prostaglandin infusion (like Flolan)
• Endothelin Receptor inhibitors (like Bosentan)