Pulmonary hypertension associated with left heart disease

Abstract

Left heart disease (LHD) is the most common cause of pulmonary hypertension (PH), which may be classified further as isolated post-capillary (ipcPH) or combined post- and pre-capillary PH (cpcPH). The 7th World Symposium on Pulmonary Hypertension PH-LHD task force reviewed newly reported randomised clinical trials and contemplated novel opportunities for improving outcome. Results from major randomised clinical trials reinforced prior recommendations against the use of pulmonary arterial hypertension therapy in PH-LHD outside of clinical trials, and suggested possible harm. Greater focus on phenotyping was viewed as one general strategy by which to ultimately improve clinical outcomes. This is potentially achievable by individualising ipcPH versus cpcPH diagnosis for patients with pulmonary arterial wedge pressure within a diagnostic grey zone (12-18 mmHg), and through a newly developed PH-LHD staging system. In this model, PH accompanies LHD across four stages (A=at risk, B=structural heart disease, C=symptomatic heart disease, D=advanced), with each stage characterised by progression in clinical characteristics, haemodynamics and potential therapeutic strategies. Along these lines, the task force proposed disaggregating PH-LHD to emphasise specific subtypes for which PH prevalence, pathophysiology and treatment are unique. This includes re-interpreting mitral and aortic valve stenosis through a contemporary lens, and focusing on PH within the hypertrophic cardiomyopathy and amyloid cardiomyopathy clinical spectra. Furthermore, appreciating LHD in the profile of PH patients with chronic lung disease and chronic thromboembolic pulmonary disease is essential. However, engaging LHD patients in clinical research more broadly is likely to require novel methodologies such as pragmatic trials and may benefit from next-generation analytics to interpret results.

FIGURE 1

Stages of pulmonary hypertension (PH) in left heart disease (LHD). ACC: American College of Cardiology; AHA: American Heart Association; HF: heart failure; LA: left atrial; WHO FC: World Health Organization functional class; ipcPH: isolated post-capillary pulmonary hypertension; cpcPH: combined post- and pre-capillary pulmonary hypertension; CO: cardiac output; mPAP: mean pulmonary artery pressure; PAWP: pulmonary artery wedge pressure; PVR: pulmonary vascular resistance; PA: pulmonary artery; RV: right ventricle; SGLTi: sodium glucose transport protein 2 inhibitor; GLP: glucagon-like peptide. ^#: disease-specific guidelines must be applied, i.e. HF (HF with reduced ejection fraction, HF with mid-range ejection fraction, HF with preserved ejection fraction), specific cardiomyopathies, valvular heart diseases. Created with BioRender.com.