Treating Pulmonary Hypertension

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The primary treatment of pulmonary hypertension is to catch the process early, and identify and treat the underlying cause. However, in many patients with this condition, more advanced therapy becomes necessary.

Baseline Assessment

The first step in treating pulmonary hypertension is to assess the baseline severity of the condition. This testing helps the doctor decide how aggressive to be with treatment, and provides a way to assess the response to therapy.

This is usually done by performing an echocardiogram, which will provide an estimate of the pulmonary artery pressure, and an exercise test to measure baseline functional capacity.

Treatment Aimed at the Underlying Medical Condition

Typically, aggressively treating the underlying cause of pulmonary hypertension is the most critical aspect of therapy. Since there are many medical disorders that can produce pulmonary hypertension, this therapy can take many different forms.

Treatments Often Useful for Anyone With Pulmonary Hypertension

In addition to therapy aimed specifically at treating the underlying cause, there are treatments that are often helpful in anyone who has pulmonary hypertension.

These include:

  • Diuretics such as Lasix or Bumex are often used to treat the fluid retention that frequently occurs with pulmonary hypertension. While diuretics can improve dyspnea and edema (swelling), they must be used carefully since getting rid of too much fluid in patients with pulmonary hypertension can worsen cardiac function.
  • Oxygen therapy is important in anyone with pulmonary hypertension who has hypoxia (reduced blood oxygen levels). When hypoxia is present, administering oxygen can often directly reduce pulmonary artery pressures. Patients whose pulmonary hypertension is caused by lung diseases or cardiac diseases are especially likely to have hypoxia, but anyone with pulmonary hypertension should have their blood oxygen levels checked.
  • Anticoagulants such as Coumadin are often used in patients with pulmonary hypertension. This is because the pulmonary hypertension itself can result in sluggish blood flow through the pulmonary circulation, which can lead to clotting within the blood vessels in the lungs. Read about drugs used to prevent blood clots.
  • Digoxin can improve cardiac function in some patients with pulmonary hypertension.
  • Exercise has been shown to significantly improve the functional capacity of people with pulmonary hypertension.

Advanced Therapy For Pulmonary Hypertension

"Advanced therapy" for pulmonary hypertension is aimed at the pulmonary hypertension itself, rather than the underlying cause. This therapy generally consists of using vasodilator drugs to attempt to dilate the pulmonary circulation and reduce pulmonary artery pressures.

Advanced therapy is called "advanced" not because it is more effective than the more general therapies, but because it is complex, relatively risky, very expensive, and often inconvenient (for instance, it may require intravenous therapy).

Advanced therapy should only be administered by physicians who are expert in treating pulmonary hypertension.

Advanced therapy is considered in patients with severe pulmonary hypertension that has not adequately responded to treatment aimed at the underlying cause, or, especially, if no underlying cause has been identified (that is, in people with primary pulmonary hypertension).

Advanced therapy is usually not used at all in people whose pulmonary hypertension is due to underlying heart disease (where advanced therapy has been shown to be more likely to cause harm), or to lung disease (where there is a lack of data showing benefit).

Before attempting advanced therapy, a specialized cardiac catheterization study is done to assess the "vasoreactivity" of the pulmonary circulation. During this test drugs are given to assess whether the pulmonary blood vessels are capable of dilating. If so, certain types of advanced therapy are more likely to be effective.

Many drugs have been developed for treating pulmonary hypertension, including:

  • Calcium channel blockers such as diltiazem and nifedipine
  • Prostanoids such as epoprostenol (Flolan), treprostinil (Remodulin) and iloprost (Ventavis)
  • Endothelin receptor antagonists such as bosentan (Tracleer), ambrisentan (Letaris), and macitentan (Opsumit)
  • PDE5 inhibitors such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra)
  • Guanylate cyclase stimulant such as riociguat (Adempas)

This long list of choices makes the process of selecting the "best" drug - or the "best" combination of drugs - exceedingly complex. Several factors have to be taken into consideration in making this selection, including the underlying disease, the severity of the pulmonary hypertension, the degree of vasoreactivity, whether certain drugs are covered by medical insurance, and the likely side effects. This is why such decisions should be made by doctors who are experts in treating pulmonary hypertension.

Summary

The optimal treatment for pulmonary hypertension can be difficult and complex. Patients with pulmonary hypertension do best who form a close working partnership with their doctors, taking an active role in deciding on therapy, in carefully observing and reporting on the status of their symptoms and functional capacity, and following the agreed upon treatment regimen very closely.

McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009; 53:1573.

Galiè N, Corris PA, Frost A, et al. Updated treatment algorithm of pulmonary arterial hypertension. J Am Coll Cardiol 2013; 62:D60.

Sources:

Galie, N, Hoeper, MM, Humbert, M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2009; 34:1219.

McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009; 53:1573.

Galiè N, Corris PA, Frost A, et al. Updated treatment algorithm of pulmonary arterial hypertension. J Am Coll Cardiol 2013; 62:D60.

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