Why Is It Critical To Suspect PH in Your Patient Evaluation?

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Dr. McLaughlin:
Hello, and welcome to this segment on why it is critical to suspect pulmonary hypertension in your patient evaluation, and what role echocardiography should play. I'm Vallerie McLaughlin, a Cardiologist at the University of Michigan. And I'm really glad that you could join me today.

Well, let's face it, it's really difficult to diagnose pulmonary hypertension because the presenting symptom, dyspnea, is so common. And it can be the presenting symptom of many other diagnoses. As you can see, here's a whole bunch of differential diagnoses that might be associated with dyspnea. And of course, the ones on the right in blue are common cardiopulmonary diseases that general internists, cardiologists, and pulmonologist see all the time. And common things happen commonly, so we're always on the lookout for things like heart failure and COPD. But pulmonary hypertension is less common. And so it often doesn't rise to the top of the differential diagnosis.

It's really important to ask the right questions, do a good physical examination, sometimes the family history and past medical history is really important in helping you to make the correct diagnosis of pulmonary hypertension.

But one of the things that really helps us further refine the diagnosis is the echo. You know, honestly, most of the patients that make it to my clinic get there because someone has done an echo, and it demonstrates an elevated estimated RVSP, and so they send them to us. But wow, there are many things that can cause pulmonary hypertension and an elevated RVSP on echo, as well. It's also important to remember that the echo is not always perfect in the estimation of RVSP. You can imagine that you can see a patient with an estimated RVSP of 51 on an echo, and it still doesn't tell you what the diagnosis is. Gosh, it could still be left heart disease,

LV systolic dysfunction, LV diastolic dysfunction, valvular disease, it could still be a pulmonary disease that causes hypoxemia. It could be a PE or chronic thromboembolic disease, or it could be really pulmonary arterial hypertension, which we'll talk about in much more detail. Or honestly, it could be an inaccurate measurement. There are limitations to the measurement of RVSP on echocardiogram, and that's one of the things I really hope will be highlighted in this course, because there are so many other things on echo that are important clues to the diagnosis of pulmonary hypertension that can push you one way or another in the differential diagnosis.

So again, it's important to not overemphasize, or to not underemphasize rather, the role of echo in the evaluation of pulmonary hypertension. And I'm really hopeful that this program will highlight some of these important features, and really what to look for and how to make the most out of echocardiography.

I also want to emphasize that there are some underlying diagnoses that should increase your index of suspicion for pulmonary hypertension. All of the rheumatologic diseases can be associated with pulmonary hypertension, pretty much any parenchymal lung disease, anything that causes hypoxemia, such as pulmonary fibrosis, can cause pulmonary hypertension. Congenital heart disease, liver disease, HIV all are associated with higher likelihoods of group 1 pulmonary arterial hypertension. It's really important to think about pulmonary embolism as well. Most patients resolve their pulmonary embolism. But they - some patients don't resolve it and they go on to develop this very rare disease called chronic thromboembolic pulmonary hypertension. And then there are other less common causes of pulmonary hypertension, such as schistosomiasis. So this is really important to take into account as you go through the different differential diagnosis of pulmonary hypertension and unexplained dyspnea.

So I hope that this has really emphasized the importance of echocardiography in your workup of patients with dyspnea. And I really hope that you learn a lot from the other segments in this section. Thank you for joining me today.

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