A 60-year-old woman has had progressive shortness of breath and dry cough over the last 2 months. The patient has no known medical problems and takes no medications. She does not use tobacco, alcohol, or illicit drugs. Family history is insignificant. Her blood pressure is 155/92 mm Hg, and pulse is 96/min and regular. Pulse oximetry shows 92% on room air. BMI is 31 kg/m². The jugular venous pressure is estimated at 9 cm H₂O. A 2/6 systolic murmur is heard at the lower sternal border and increases with inspiration. Lung auscultation reveals scattered wheezes and bibasilar crackles. There is 2+ symmetric peripheral edema. Echocardiogram shows a dilated left ventricle with ejection fraction of 30% and a mildly dilated right ventricle. The pulmonary artery systolic pressure is estimated at 55 mm Hg (normal

Question

A 60-year-old woman has had progressive shortness of breath and dry cough over the last 2 months. The patient has no known medical problems and takes no medications. She does not use tobacco, alcohol, or illicit drugs. Family history is insignificant. Her blood pressure is 155/92 mm Hg, and pulse is 96/min and regular. Pulse oximetry shows 92% on room air. BMI is 31 kg/m². The jugular venous pressure is estimated at 9 cm H₂O. A 2/6 systolic murmur is heard at the lower sternal border and increases with inspiration. Lung auscultation reveals scattered wheezes and bibasilar crackles. There is 2+ symmetric peripheral edema. Echocardiogram shows a dilated left ventricle with ejection fraction of 30% and a mildly dilated right ventricle. The pulmonary artery systolic pressure is estimated at 55 mm Hg (normal <35 mm Hg). Which of the following is the best initial treatment for this patient's pulmonary hypertension?

Quizplus · Accepted Answer

This patient's progressive shortness of breath, tricuspid regurgitation (systolic murmur at the sternal border, increased with inspiration), peripheral edema, and echocardiogram findings are suggestive of pulmonary hypertension (PH). PH is defined as mean pulmonary arterial pressure of >25 mm Hg at rest (normal <20 mm Hg). PH can be idiopathic (group 1 PH) or secondary to left heart disease, chronic lung disease, or chronic thromboembolism, and is often multifactorial. pulmonary hypertension > < This patient's PH is likely due to severe left ventricular (LV) systolic dysfunction (reduced ejection fraction and signs of pulmonary edema), which is a common cause of PH. Management of PH due to LV systolic dysfunction should include loop diuretics and ACE inhibitors (or angiotensin II receptor blockers), often with beta blockers, and in some cases aldosterone antagonists. (Choices A and B) Oxygen and/or bronchodilator therapy is indicated for PH due to hypoxemia from chronic lung disease. This patient has severe LV dysfunction and no history of lung disease. (Choices D and G) Endothelin receptor antagonists (eg, bosentan), phosphodiesterase-5 inhibitors (eg, sildenafil), and/or prostanoids (eg, epoprostenol) are indicated for symptomatic idiopathic PH. These agents are not currently indicated for PH due to LV dysfunction. (Choice E) Graded exercise training improves long-term outcomes (walking distance, peak oxygen consumption, overall functional status) in all patients with PH, with or without LV systolic dysfunction. However, this patient first needs appropriate stabilization of her underlying cardiac disease. (Choice F) Long-term anticoagulation is indicated for patients with PH due to chronic thromboembolic occlusion of pulmonary vasculature. These patients typically have normal LV systolic function. Educational objective: Left ventricular systolic or diastolic dysfunction is a common cause of pulmonary hypertension. Initial management includes loop diuretics and ACE inhibitors (or angiotensin II receptor blockers). References: Definitions and diagnosis of pulmonary hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/24355641) Pulmonary hypertension secondary to left ventricular systolic dysfunction: contemporary diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/19032918) Clinical features, hemodynamics, and outcomes of pulmonary hypertension due to chronic heart failure with reduced ejection fraction: pulmonary hypertension and heart failure. (http://www.ncbi.nlm.nih.gov/pubmed/24621932)

A 60-Year-Old Woman Has Had Progressive Shortness of Breath and Dry