Pulmonary hypertension (PH) can be a severe and potentially debilitating complication in patients with chronic left-sided heart failure (HF). In a review published in Heart Failure Clinics, researchers from Germany and Italy provided recommendations on assessment and an overview of targeted management strategies that may be helpful for these patients.
The presence of PH in patients with left-sided HF can confer poor prognosis and survival, making appropriate assessment of the condition crucial for optimizing outcomes. According to the researchers, right heart catheterization or a fluid challenge may be indicated in some patients at intermediate risk in an effort to obtain a correct diagnosis. A pulmonary arterial wedge pressure (PAWP) of ≥15 mm Hg is a mandatory criterion for establishing PH associated with left-sided HF.
Guidelines recommend that PAWP should be assessed at end-expiration at rest using a proper “zero” point at the mid-chest. A provocative test should be used to confirm PAWP findings in patients with borderline PAWP values (ie, 13-15 mm Hg) or in patients with lower PAWP but who present with echocardiographic signs of left ventricular hypertrophy.
There are currently no approved targeted therapies for patients with PH and right HF with preserved ejection fraction (EF) or HF with reduced EF. Clinical trials are currently ongoing to test drugs that either activate guanylate cyclase or inhibit phosphodiesterase type 5 in patients with PH and HF with preserved EF. These studies include the DYNAMIC trial (Pharmacodynamic Effects of Riociguat in Pulmonary Hypertension and Heart Failure With Ejection Fraction; ClinicalTrials.gov Identifier: NCT02744339) and the PASSION Study (Phosphodiesterase-5 Inhibition in Patients With HF With Preserved Ejection Fraction and Combined Post- and Pre-Capillary PH; European Union Clinical Trials Register No.: 2017-003688-37).
The investigators suggested exercise training, a guideline-recommended treatment, may be beneficial in some individuals. In the context of PH with left-sided HF, exercise training may be associated with improvements in exercise capacity. In patients with right ventricular failure whose prognoses do not improve despite use of vasopressors and inotropes, mechanical circulatory is often necessary.
“A profound understanding of the mechanisms that may lead to the development of PH [caused by chronic left-sided HF] might be helpful to improve the management of these patients,” the researchers wrote.
Marra A-M, Benjamin N, Cittadini A, Bossone E, Grünig E. When pulmonary hypertension complicates heart failure. Heart Fail Clin. 2020;16(1):53-60.