Group II Pulmonary Hypertension Due To Left Heart Disease
According to WHO, the pulmonary hypertension (PH) is classified into five main groups. Pulmonary hypertension because of left heart disease is placed in group II. It is one of the devastating and complex diseases associated with high rate of mortality. It affects the left side of the heart causing myocardial dysfunction, valvular disease, and poor ejection fraction (systolic heart failure). The most important hemodynamic feature (dynamics of blood flow) that distinguish group II pulmonary hypertension from other is elevated pulmonary capillary wedge pressure i.e. greater than 15 mmHg (normal level is less than or equal to 15 mmHg).
Group II pulmonary hypertension affected individuals possibly will present with a high level of pulmonary arterial pressure (PAP). Sometimes, patients may develop to sensitive PH stage, with an increase in transpulmonary gradient and pulmonary vascular resistance. This often described as a precapillary or mixed group. The precise mechanism of the cause of this group-II disease in patient is not understood completely. But expert identified that pressures increase or pulmonary edema is the reason for localized impairment. Metalloproteinase, endothelin, and angiotensin II activation causes tissue modifications and vasoconstriction. This also mediates fibroblast proliferation, which results in permanent vascular alteration.
Group II Associated With Comorbid Conditions
PH due to left heart disease is often associated with other disease. This condition medically referred as a comorbid state, which can increase the symptoms of myocardial dysfunctions, and chronic kidney disease. Ischemic heart disease, hyper blood pressure, pulmonary obstructive syndrome, sleep apnea, and diabetes mellitus are all associated with group II and can increase the risk of mortality.
Importance of Diagnostic Measures
Measurement of pulmonary pressure is the ideal procedure for evaluation. In addition, the myocardial or valvular abnormalities can be effortlessly measured by the echocardiogram. Left ventricular diastolic function often is left out in group II patients. It is the main reason for the cause of the heart failure in many cases. Early diagnosis of diastolic dysfunction is often able to reverse mitral valve disorders.
Right heart catheterization is the standard method for identifying PH and precapillary PH because of PVDs from left sided heart failure. PH related to systolic heart failure more frequently ends in death. It is the main obstacle for heart transplantation in patients with end-stage heart failure, with the exception being only if the PH cases are reversible.
One of the most interesting approaches to measuring PH is by utilizing exercise test. Prone bicycle ergometry is a vigorous form of exercise, which assists in the evaluation of the modifications in left ventricular and pulmonary filling pressures. It is also helpful for assessing increasing cardiac output. The data obtained from exercise test makes the experts identify pulmonary hypertension during the initial stages and differentiate left ventricular disease from PVD.
Treatments for Group II
Initial diagnosis and treatment of symptoms can able to reduce the morbidity like valve or myocardial diseases. Managing blood pressure, treating sleep apnea, maintaining optimal weight, treating valvular heart diseases, and treating CAD based on American College of Cardiology (ACC) and American Heart Association guidelines needs to be considered first before treating PH. PH may resolve significantly in many cases once the patient’s volume has normalized. PH can elevate the local injury level, particularly in valvular heart disease patients. In such cases, if vasodilator therapy is initiated before the onset of valve disease, due to the risk of adverse effects from drug administration, it may lead to heart failure.
Systolic heart failure must be treated with neurohormonal blockades such as beta blocker, ACE inhibitors, angiotensin receptor blocker, and aldosterone antagonists.
A neprilysin inhibitor called Sacubitril is quite an effective way to cut down the risk of death due to heart failure when used in combination with angiotensin receptor blockers. It is promising treatment for systolic heart failure patients. Similarly, management by use sildenafil drugs is effective in improving the blood flow (hemodynamics) in addition to a reduction in heart failure-related symptoms. Prostaglandin and milrinone are also identified as effective for PH.
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