Diagnosis of pulmonary arterial hypertension: a statement from the Brazilian Thoracic Association

Figures

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  Figure 1. Electrocardiogram, chest CT, and chest radiograph in pulmonary hypertension. Three tests were conducted to investigate pulmonary hypertension in a 32-year-old female patient diagnosed with PAH. ECG: right ventricular hypertrophy with right axis deviation, P pulmonale (black arrow), and right ventricular strain pattern (ST depression in leads II, III, and aVF and T inversion in V1-2, red arrows). Chest contrast-enhanced CT: pulmonary artery enlargement (> 29 mm - black line) and a pulmonary artery/aorta ratio greater than 1.0 (aorta diameter - red line). Chest radiograph (frontal): cardiomegaly with an elevated cardiac apex (yellow star), prominent pulmonary trunk (yellow arrow), and enlarged pulmonary arteries (blue arrow). PAH: pulmonary arterial hypertension; and ECG: electrocardiogram.

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  Figure 2. Dual-energy CT of the chest and lung perfusion scintigraphy. Dual-energy CT iodine map and lung perfusion scintigraphy used to investigate pulmonary hypertension. In this case, the two diagnostic methods agree and show hypoperfusion in the left lower lobe (yellow arrow).

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  Figure 3. Echocardiogram parameters in pulmonary hypertension. RV: right ventricle; LV: left ventricle; RA: right atrium; TAPSE: tricuspid annular plane systolic excursion; S’: peak systolic velocity of tricuspid annulus; FAC: fractional area change; and IVC: inferior vena cava.

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  Figure 4. (A) Fluoroscopy image performed during a right heart catheterization. (B) Graphic representation of the pressure waveforms. RA: right atrium; RV: right ventricle; PA: pulmonary artery; and PAWP: pulmonary arterial wedge pressure.

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  Figure 5. Diagnostic algorithm for pulmonary hypertension. Algorithm for clinical investigation of patients with exertional dyspnea and suspected pulmonary hypertension. BNP/NT-proBNP: brain natriuretic protein/N-terminal pro-brain natriuretic peptide; CTEPH: chronic thromboembolic pulmonary hypertension; ECG: electrocardiogram; PH: pulmonary hypertension; US: ultrasonography; V/Q scan: ventilation/perfusion scintigraphy. aComplementary investigation including pulmonary function tests and cardiopulmonary exercise testing. bVasoreactivity test for patients suspected of idiopathic, drug-associated, or hereditary pulmonary hypertension; consider volume load test if heart failure with preserved ejection fraction is suspected; exercise test must be considered in some cases. cExercise assessment can be noninvasive, but in some cases exercise right heart catheterization must be considered.

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  Figure 6. Pulmonary arterial hypertension risk stratification. WHO-FC: World Health Organization functional class; VO2: oxygen uptake; pred.: predicted; VE/VCO2: ventilatory equivalents for carbon dioxide; BNP: brain natriuretic peptide; NT-proBNP: N-terminal pro-brain natriuretic peptide; RA: right atrium; TAPSE: tricuspid annular plane systolic excursion; sPAP: systolic pulmonary arterial pressure; RVEF: right ventricular ejection fraction; SVI: stroke volume index; RVESVI: right ventricular end-systolic volume index; RAP: right atrial pressure; CI: cardiac index; and SvO2: mixed venous oxygen saturation.