A 72-year-old man is evaluated for progressive exertional dyspnea over the last 2-3 years. His current exercise tolerance is walking one block on flat ground, and he gets very short of breath when climbing stairs. He takes amlodipine for hypertension.
Blood pressure is 154/90 mm Hg, pulse is 88/min, and oxygen saturation at rest is 96%. BMI is 32 kg/m². Breath sounds are decreased at the lung bases with scattered crackles. The remainder of the examination is within normal limits.
Transthoracic echocardiogram shows moderate left atrial enlargement, mild left ventricular hypertrophy, normal valves, and left ventricular ejection fraction of 60%. Coronary angiography shows no obstructive coronary disease. Right heart catheterization shows pulmonary capillary wedge pressure of 28 mm Hg and pulmonary artery pressure of 70/30 mm Hg (mean pressure 42 mm Hg) .
Which of the following is the best initial management for this patient?

Question

Quizplus · Accepted Answer

This patient's right heart catheterization reveals a mean pulmonary arterial pressure >25 mm Hg, which is consistent with pulmonary hypertension (PH). The study also shows a pulmonary capillary wedge pressure (PCWP) >15 mm Hg, suggestive of left-sided heart failure. In this patient with likely long-standing systemic hypertension and normal left ventricular (LV) ejection fraction, the most likely diagnosis is PH secondary to heart failure with preserved ejection fraction (LV diastolic dysfunction). Concentric hypertrophy of the left ventricle leads to impaired diastolic filling, increased left atrial pressure, pulmonary edema, and transmission of increased hydrostatic pressure back to the pulmonary arteries. Left-sided heart disease, in the form of LV systolic dysfunction, LV diastolic dysfunction, or mitral or aortic valve dysfunction, is one of the most common causes of PH. causes of PH Diuresis with furosemide is the most appropriate initial management in this dyspneic patient with LV diastolic dysfunction and evidence of volume overload (eg, elevated PCWP, bibasilar crackles). Following diuresis to euvolemia, ongoing management will involve maintenance diuretics and control of systemic hypertension. (Choice A) Bosentan is an endothelin receptor antagonist that is an effective treatment for some patients with idiopathic pulmonary arterial hypertension (group 1 PH); however, it is not effective for PH secondary to left-sided heart disease. (Choice B) Certain beta blockers (eg, carvedilol, extended-release metoprolol, bisoprolol) are a mainstay of therapy in patients with LV systolic dysfunction; however, their benefit is unclear in patients with LV diastolic dysfunction. Following diuresis this patient may require additional antihypertensive therapy, for which the addition of carvedilol would be appropriate. (Choice D) Nocturnal oxygen may benefit some patients with PH secondary to chronic lung hypoxia due to pulmonary disease (eg, chronic obstructive pulmonary disease, interstitial lung disease) (group 3 PH), but it is unlikely to be helpful in this patient. (Choice E) Chronic anticoagulation (eg, rivaroxaban) is indicated in patients with PH secondary to chronic thromboembolic disease (group 4 PH), but it has no role in PH secondary to left-sided heart disease. Educational objective: Decompensated left ventricular diastolic dysfunction is a common cause of secondary pulmonary hypertension. Patients demonstrate normal left ventricular ejection fraction on echocardiogram, as well as elevated mean pulmonary arterial pressure >25 mm Hg and pulmonary capillary wedge pressure >15 mm Hg on right heart catheterization. Diuresis to euvolemia is the most appropriate initial management. __________ References: Pulmonary hypertension due to left heart diseases. (http://www.ncbi.nlm.nih.gov/pubmed/24355634) The pathophysiology of heart failure with preserved ejection fraction. (http://www.ncbi.nlm.nih.gov/pubmed/24958077) Pulmonary hypertension in heart failure with preserved ejection fraction: a community-based study. (http://www.ncbi.nlm.nih.gov/pubmed/19324256)

A 72-Year-Old Man Is Evaluated for Progressive Exertional Dyspnea Over