The first step to
answering this question requires the calculation of the transpulmonary
gradient (TPG) using the following formula:
TPG = mean PA pressure – PAWP = 33 - 11 = 22 mmHg
The PVR can now be calculated using the following formula:
PVR = TPG/cardiac output = (22 mmHg)/(4.17 L/min) = 5.28 woods units (mmHg/L/min)
Discussion
The patient in this case has a mean pulmonary artery pressure (mPAP)
of 33 mmHg, which is diagnostic of pulmonary hypertension. The cause of
this patient’s pulmonary hypertension can be further evaluated by using
the PVR and PAWP. By definition, mPAP greater than 25 mmHg with low PAWP
(≤ 15 mmHg) and a high PVR (>3 Wood units) is consistent with
pre-capillary pulmonary hypertension.1
There are 4 main types of pulmonary hypertension that result in
elevated pre-capillary pulmonary pressures. These include pulmonary
arterial hypertension, pulmonary hypertension secondary to lung disease
and/or hypoxemia, chronic thromboembolic pulmonary hypertension (CTEPH),
and pulmonary hypertension with unclear and/or multifactorial
mechanisms (Group 5 PH).1 The patient in this case underwent
extensive evaluation and did not have significant chronic lung disease
or chronic thromboembolic disease. In the setting of systemic lupus
erythematosus, this patient’s pre-capillary pulmonary hypertension was
attributed to connective tissue disease associated pulmonary arterial
hypertension (CTD-PAH). According to the US REVEAL registry2,
approximately 17% of patients with pulmonary hypertension secondary to
connective tissue disease had a diagnosis of SLE. The 1-year and 2-year
survival for pulmonary hypertension secondary to SLE is estimated to be
94% and 85% respectively.2
Management of pulmonary arterial hypertension includes an evaluation
of a patient’s WHO functional class and treatment with vasodilator
therapy. The patient in this case met criteria for WHO functional class
3. Vasodilator therapy was initiated using Phosphodiesterase-5 inhibitor
(tadalafil), which has been shown to improve exercise tolerance and
quality of life.3 Once the patient tolerated tadalafil, she
was subsequently started on an endothelin receptor antagonist
(Macitentan), which has been shown to delay time to clinical worsening.4
References
-
Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for
the Diagnosis and Treatment of Pulmonary Hypertension. Rev Esp Cardiol
(Engl Ed). 2016 Feb;69(2):177.
-
Chung L, Liu J, Parsons L, et al. Characterization of connective
tissue disease-associated pulmonary arterial hypertension from REVEAL:
identifying systemic sclerosis as a unique phenotype. Chest. 2010
Dec;138(6):1383-94.
-
Galiè N, Brundage BH, Ghofrani HA, et al. Tadalafil therapy for
pulmonary arterial hypertension. Circulation. 2009 Jun
9;119(22):2894-903.
-
Pulido T, Adzerikho I, Channick RN, et al. Macitentan and morbidity
and mortality in pulmonary arterial hypertension. N Engl J Med. 2013 Aug
29;369(9):809-18.