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. 2014 Jan;7(1):116-22.
doi: 10.1161/CIRCHEARTFAILURE.113.000468. Epub 2013 Dec 2.

High prevalence of occult pulmonary venous hypertension revealed by fluid challenge in pulmonary hypertension

Ivan M Robbins  1 , Anna R Hemnes, Meredith E Pugh, Evan L Brittain, David X Zhao, Robert N Piana, Pete P Fong, John H Newman
Affiliations

High prevalence of occult pulmonary venous hypertension revealed by fluid challenge in pulmonary hypertension

Ivan M Robbins et al. Circ Heart Fail. 2014 Jan.

Abstract

Background: Determining the cause for pulmonary hypertension is difficult in many patients. Pulmonary arterial hypertension (PAH) is differentiated from pulmonary venous hypertension (PVH) by a wedge pressure (PWP)>15 mm Hg in PVH. Patients undergoing right heart catheterization for evaluation of pulmonary hypertension may be dehydrated and have reduced intravascular volume, potentially leading to a falsely low measurement of PWP and an erroneous diagnosis of PAH. We hypothesized that a fluid challenge during right heart catheterization would identify occult pulmonary venous hypertension (OPVH).

Methods and results: We reviewed the results of patients undergoing fluid challenge in our pulmonary hypertension database from 2004 to 2011. Baseline hemodynamics were obtained and repeated after infusion of 0.5 L of normal saline for 5 to 10 minutes. Patients were categorized as OPVH if PWP increased to >15 mm Hg after fluid challenge. Baseline hemodynamics in 207 patients met criteria for PAH. After fluid challenge, 46 patients (22.2%) developed a PWP>15 mm Hg and were reclassified as OPVH. Patients with OPVH had a greater increase in PWP compared with patients with PAH, P<0.001, and their demographics and comorbid illnesses were similar to patients with PVH. There were no adverse events related to fluid challenge.

Conclusions: Fluid challenge at the time of right heart catheterization is easily performed, safe, and identifies a large group of patients diagnosed initially with PAH, but for whom OPVH contributes to pulmonary hypertension. These results have implications for therapeutic trials in PAH and support the routine use of fluid challenge during right heart catheterization in patients with risk factors for PVH.

Keywords: hemodynamics; hypertension, pulmonary; pulmonary arterial hypertension; pulmonary heart disease.

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Figures

Figure 1
Figure 1. Patient diagnoses
Two-hundred and seven patients were diagnosed with pulmonary arterial hypertension (PAH) after baseline hemodynamics were obtained. Following fluid challenge, the pulmonary wedge pressure in 46 patients increased to >15 mm Hg, and they were reclassified as occult pulmonary venous hypertension (OPVH). PAH-BL=pulmonary arterial hypertension baseline; PAH-F= pulmonary arterial hypertension final; PVH=pulmonary venous hypertension; No PH=no pulmonary hypertension.
Figure 2
Figure 2. Univariate predictors for the development occult pulmonary venous hypertension (OPVH) following fluid challenge in patients initially diagnosed with pulmonary arterial hypertension
Results are expressed as odds ratio with 95% confidence intervals. BMI=body mass index, CAD=coronary artery disease, DM=diabetes mellitus, HL=hyperlipidemia, HTN=hypertension, LAE=left atrial enlargement on echocardiogram, LVH=left ventricular hypertrophy on echocardiogram. OSA=obstructive sleep apnea.
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