New European recommendations for the management of pulmonary hypertension

barcelona, ​​spain – of European Society of Cardiology (ESC) and Respiratory Society (ERS) Updated recommendations for diagnosis and treatment of pulmonary hypertension (PH). Seven years after the previous version, it brings novelty to hemodynamic definitions, diagnostic approaches, risk assessment and treatment strategies. Angioplasty is also becoming the treatment of choice for chronic thromboembolic pulmonary hypertension.

Recommendations were presented at the General AssemblyESC 2022 simultaneously published inEuropean Heart Journal and European Respiratory Journal [1,2] They were also presented at a conference a little later‘ERS 2022.

“These recommendations first change the hemodynamic definition of pulmonary hypertension and represent a major shift in clinical practice. Identify new populations of patients at risk of developing disease. Medscape French version, Professor David Montani (Department of Respiratory and Thoracic Intensive Care, Pulmonary Hypertension Reference Center, Hospital Bicetre, AP-HP, Le Kremlin Bicetre).

Diagnosis of PH is often delayed, sometimes two years or more after the first symptoms appear, but this new definition should facilitate early diagnosis.

New patient diagnosis

Diagnosis of PH requires performing right heart catheterization to measure mean pulmonary artery pressure (PAP), occlusion PAP, and calculation of pulmonary valve resistance (PVR).

PH is now defined by an increase in mean PAP > 20 mmHg (vs. ≥ 25 mmHg in previous recommendations). We distinguish:

  • Precapillary PH: occlusion PAP ≤ 15 mmHg and pulmonary vascular resistance PVR > 2 UW

  • Postcapillary HTP: Occluded PAP > 15 mmHg and RVP ≤ 2 UW (isolated postcapillary morphology) or RVP > 2 UW (combined precapillary and postcapillary morphology).

The vascular resistance threshold was previously set at 3 UW.

Diagnosis of PH is often delayed, but this new definition should facilitate early diagnosis.

As a reminder, a normal average PAP value is 10-14 mmHg with a vascular resistance of about 1 UW. This new definition suggests that patients with intermediate thresholds (mean PAP between 21 and 24 and PVR between 2 and 3 UW) “pre-exist with prognostic pulmonary vascular disease” Especially retrospectively follow her cohorts.

“For chronic thromboembolic pulmonary hypertension, data show that patients already have pulmonary vascular involvement between 2 and 3 UW. It has also been shown that patients with pneumonia develop pulmonary hypertension. [selon l’ancienne définition basée sur le seuil des 25 mmHg] in the next year. »

This change in definition “enables early diagnosis” of pulmonary hypertension in at-risk patients. Nonetheless, due to the lack of data on the efficacy of treatment at this level of her PH, no recommendations can be made as to which treatment strategy to implement, he emphasizes Professor Montani. If the PH falls below the old threshold, “without systematic treatment”, “thus close follow-up is recommended”.

The recommendation states that identification of this new population of patients with mild PH will involve “better understanding of the natural evolution of these patients, assessing the impact of treatment at this early stage of disease, and assessing whether screening strategies are effective.” We need to do research to determine if it’s right,” the expert adds.

“Echocardiography, used when minimal PH is suspected, is sometimes the default in these patients. should be evaluated.”

Simplified diagnostic algorithm

The new version of this recommendation also simplifies the diagnostic approach. If laboratory test results are questionable, resting transthoracic echocardiography should be performed to determine the possibility of PH. If there is a moderate or high likelihood, the patient should be referred to her PH reference center for right heart catheterization to be performed to confirm the diagnosis.

Measurement of maximum tricuspid flow velocity by transthoracic echocardiography remains the cornerstone of PH screening. This reading should be interpreted in the light of other ultrasound indications suggestive of PH. Two new indications were added: TAPSE/PAPs ratio < 0.55 mm/mm Hg and pulmonary artery diameter greater than aortic diameter.

Screening clarifications were made for high-risk patients. Asymptomatic patients at high risk (e.g., scleroderma, relatives with mutations in the PH predisposition gene, liver transplantation) and if respiratory distress develops after an episode of pulmonary embolism should be intensified.

Sophisticated Mortality Risk Stratification

if pulmonary artery hypertension (PAH), prognosis, treatment strategies, and follow-up should be based on low risk (risk of death at 1 year). <5%)、中リスク (5 ~ 20%)、および高リスク (>20%).

Risk is based on a variety of documented parameters (presence of clinical signs of heart failure, NYHA functional class of dyspnea, 6-minute walk test, hemodynamic parameters, echocardiography, BNP/NT-proBNP, etc.). is evaluated as ). “This assessment has been refined with these new recommendations,” said Professor Montani.

With regard to treatment management, recommendations currently distinguish between patients with and without cardiopulmonary comorbidities. In the absence of comorbidities, low-risk or intermediate-risk patients are recommended to be treated with dual therapy combining a phosphodiesterase 5 (iPDE5) inhibitor and an endothelin receptor antagonist (class IA). High-risk patients should receive additional prostacyclin analogues.

In patients with multiple cardiopulmonary comorbidities, monotherapy is offered as first-line therapy with close follow-up. (Class IIa).

With regard to treatment management, recommendations currently distinguish between patients with and without cardiopulmonary comorbidities.

As part of follow-up, alternative risk stratification, including ‘non-invasive’ parameters, can be used during evaluation. It distinguishes four levels (low risk, low-intermediate risk, high-intermediate risk, and high risk) and is based solely on the NYHA functional class, the 6-minute walk test, and the BNP/NT-proBNP assay.

“Previously, during follow-up, patient assessment often led to the implementation of right heart catheterization. can be expected to rely on,” Professor Montani emphasizes.

aboutPostcapillary pulmonary hypertension, the peculiarities of management are recalled. Recommendations recommend evaluating the possibility of postcapillary PH before performing right heart catheterization according to various criteria. For example, if age exceeds her 70 years, the presence of pre-existing atrial fibrillation or dilation of the right chamber is prognostic.

Additionally, if left heart disease is present, it is advisable to optimize treatment for heart disease before considering a diagnosis of PH (Class I, A).

A multimodal approach in thromboembolic PH

aboutchronic thromboembolic pulmonary hypertension, a new diagnostic algorithm is proposed. If in doubt, it is based on echocardiography and perfusion imaging (particularly scintigraphy) before referring the patient to a referral center for diagnostic confirmation by right heart catheterization.

“The management of chronic thromboembolic pulmonary hypertension has evolved significantly in recent years,” says Professor Montani. Three therapeutic approaches are currently available. Standard surgical treatment (pulmonary thromboendoarterectomy), combined with medical treatment for endothelial dysfunction and pulmonary balloon angioplasty, can be combined according to the patient profile. Recommendations recall indications for lifelong anticoagulant therapy.

In operable patients, especially for proximal arterial obstruction, pulmonary endarterectomy (unblocking fibrous material obstructing the pulmonary artery by pulmonary endarterectomy) remains the reference treatment (Class I). “But it’s a heavy operation with circulatory arrest”. In France, only the private Marie-Lannelong hospital near Paris offers this highly specialized operation.

Pulmonary angioplasty (without stent placement) with medical intervention is now available if the material blocking the pulmonary artery is inaccessible to surgery. “Before the development of angioplasty, treatment options for these patients were limited,” said the pulmonologist.

“Currently, this approach is multimodal, allowing for the combination of three modalities, but in a specialized center, involving experts in thoracic surgery, pulmonary angioplasty, and the medical management of pulmonary hypertension. A multidisciplinary consultation is required.The best treatment strategy should be determined on a case-by-case basis according to the patient profile.”

Prior to the development of angioplasty, treatment options for these patients were limited.
Professor David Montani

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