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CHARACTERISTICS OF PULMONARY ARTERIAL HYPERTENSION ASSOCIATED WITH ELEVATED PULMONARY CAPILLARY WEDGE PRESSURE

Duke University Medical Center, Durham, NC

PURPOSE: While randomized trials of pulmonary arterial hypertension (PAH) therapy exclude patients with an elevated pulmonary capillary wedge pressure (PCWP), 25 percent of our referred pulmonary hypertension (PH) population has a PCWP > 15 mmHg. These patients often otherwise meet WHO criteria for PAH. We sought to better characterize these patients.

METHODS: We reviewed PH patients referred to our center from 2001 to 2005 to determine the characteristics of those patients with an elevated PCWP. We included those with a mPAP > 25 mmHg, and PCWP > 15 mmHg. Those with PH and abnormal LV systolic function, or pulmonary vascular resistance (PVR) < 3 were excluded. Baseline characteristics, diagnosis, disease severity, and therapy were analyzed.

RESULTS: 114 patients had normal LV function, mPAP > 25 and PCWP > 15; 29 with PVR < 3 were excluded. The remaining 85 patients had multiple comorbidities; 73.8% had hypertension, 54.1% had LV hypertrophy, and 57.6% were obese. Approximately 1/3 had one or more of the following: atrial fibrillation, coronary disease, chronic obstructive pulmonary disease or diabetes. Mean hemodynamics were as follows: mPAP 52.9 mmHg (29-138), PCWP 21.5 mmHg (16-40), PVR 7.9 Wood Units (WU) (3.1-32.9), and cardiac index (CI) 2.4 L/min/m2 (1.3-4.34). The mPAP was >55 mmHg in 36.4%, right atrial pressure >20 mmHg in 25%, and CI <2.0 L/min/m2 in 20%. Mild PH (PVR 3 to 5 WU)was present in 40%. Specific PAH therapy (e.g., prostacyclins or endothelin antagonist)was safely administered in 39/51 patients with more severe PH. Major diagnoses included PAH, (8 idiopathic, 7 connective tissue disease, 1 portopulmonary, 6 congenital heart) while left-heart / valvular disease, or primary lung or sleep disorders appeared to contribute in 30 and 23 patients respectively. The remainder had chronic thromboembolism, sarcoidosis, sickle cell, and high output disorders.

CONCLUSION: Patients with PH and an elevated PCWP but with normal LV systolic function have significant comorbidities complicating their management.

CLINICAL IMPLICATIONS: Future controlled clinical trials should study specific PAH therapy in this population.

DISCLOSURE: Terry Fortin, None.