2025 Pulmonary and Critical Care Medicine Fellows Course (INVITE ONLY)-PulmonaryHypertensionReview18October2025

PulmonaryHypertensionReview18October2025

Pdf Summary

The CHEST Fellows’ Course on October 18, 2025, presented by Drs. Talal Dahhan and Katie Fitton, provided a comprehensive review of pulmonary hypertension (PH), including its definition, diagnosis, and management.<br /><br />Pulmonary hypertension is defined hemodynamically by a mean pulmonary artery pressure (mPAP) ≥20 mmHg via right heart catheterization. Pulmonary arterial hypertension (PAH) requires mPAP ≥20 mmHg, pulmonary capillary wedge pressure (PCWP) ≤15 mmHg, and pulmonary vascular resistance (PVR) ≥2 Wood units. Cardiac output or cardiac index is critical in assessing severity. Elevated PCWP (>15) suggests pulmonary venous hypertension (Group II), while lower values point to pre-capillary diseases (Groups I, III, IV, V). Additional measures such as transpulmonary gradient and diastolic pulmonary gradient help refine diagnosis, especially distinguishing mixed forms. Fluid challenge during catheterization can unmask occult Group II disease, and exercise catheterization may reveal pre-capillary abnormalities, though availability is limited.<br /><br />General management includes cardiopulmonary rehabilitation with slow-paced respiration benefiting symptoms and inflammation. Salt and fluid restriction, along with diuretics, mitigate right heart failure effects like congestion and edema. Anticoagulation may be considered in selected patients. Correcting anemia is important to prevent right ventricular ischemia.<br /><br />Specific pharmacologic treatments target distinct pathways:<br /><br />- Nitric oxide pathway: inhaled NO, PDE-5 inhibitors such as sildenafil and tadalafil.<br />- Endothelin receptor antagonists: bosentan, ambrisentan, macitentan.<br />- Prostacyclin analogues: inhaled (iloprost, treprostinil), oral, subcutaneous, and intravenous forms with carefully managed dosing to avoid abrupt cessation.<br />- Soluble guanylate cyclase stimulator: riociguat, approved for PAH and inoperable chronic thromboembolic pulmonary hypertension (CTEPH).<br /><br />Sotatercept, a novel agent balancing proliferative signaling, shows promise in reducing PVR on top of background therapy.<br /><br />CTEPH is a uniquely potentially curable form of PH via pulmonary thromboendarterectomy surgery. Ventilation-perfusion scans are essential for screening. Inoperable cases may be managed with balloon pulmonary angioplasty and riociguat.<br /><br />These advances and diagnostic tools guide precise classification and individualized treatment to improve outcomes in pulmonary hypertension.

Keywords

Pulmonary Hypertension

Pulmonary Arterial Hypertension

Right Heart Catheterization

Mean Pulmonary Artery Pressure

Pulmonary Vascular Resistance

Cardiopulmonary Rehabilitation

Pharmacologic Treatments

CTEPH

Pulmonary Thromboendarterectomy

Balloon Pulmonary Angioplasty