Diagnostic Evaluation of Pulmonary Hypertension: A Comprehensive Approach for Primary Care Physicians

Figures

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  Figure 1. Clinical classification of pulmonary hypertension. CV: cardiovascular; e.g.: example given; HFpEF: heart failure with preserved ejection fraction; HFrEF: heart failure with reduced ejection fraction; HIV: human immunodeficiency virus; HTN: hypertension; PH: pulmonary hypertension; w/o: without. Created using Biorender.

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  Figure 2. Stepwise approach algorithm for diagnosis of pulmonary hypertension.

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  Figure 3. Electrocardiogram findings of pulmonary hypertension. This electrocardiogram demonstrates P pulmonale (arrowheads), right ventricular (RV) hypertrophy (solid arrows), RV strain (dotted arrows), and right axis deviation.

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  Figure 4. Transthoracic echocardiogram findings of precapillary pulmonary hypertension. In normal physiology, the right ventricle (RV) is approximately 2/3 of the size of the left ventricle (LV); the LV forms the apex of the heart, and the RA is similar in size to the left atrium (A). The interventricular septum (IVS) is round ((B), line), and the right ventricular outflow tract pulse wave Doppler profile (RVOT PWD) is parabolic (C). In pulmonary arterial hypertension, the RV is enlarged and apex-forming ((A’), arrow), with right atrial enlargement (A’). The IVS can flatten in systole (“pressure“ overload or high resistance) (B’). The RVOT PWD is notched in appearance ((C’), arrowhead). RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle.

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  Figure 5. Doppler echocardiographic findings in pulmonary hypertension. The right ventricular systolic pressure (RVSP) can be estimated with the velocity of the tricuspid regurgitant jet by utilizing the modified Bernoulli equation: 4 X (velocity)2 + right atrial pressure. In the absence of pulmonic stenosis, the RVSP is equal to the pulmonary artery systolic pressure (A). Tricuspid annular plane systolic excursion (TAPSE) is obtained by placing the M-mode cursor in line with the tricuspid annulus. The degree of excursion is utilized to estimate right heart function (B). In this patient, the TAPSE is abnormal at 1.0 cm (normal > 1.8 cm).

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  Figure 6. Thoracic imaging of pulmonary hypertension. (A) Chest X-ray with prominent pulmonary artery markings. (B) CT chest with dilated main pulmonary artery, which is larger than the ascending aorta. (C) Perfusion scan with arrows marking abnormal perfusion defects.