Diagnosis and Assessment of Disease Severity Diagnosis:
ÎThe proposed new definition of PH is a resting mPAP ≥ 25 mm Hg. PAH adds the criterion that the pulmonary arterial wedge pressure must be ≤ 15 mm Hg. (A resting mPAP of 8 to 20 mm Hg should be considered normal, based on available evidence, and an mPAP of 21-24 mm Hg is considered "borderline.")
ÎDue to the complexity of the diagnostic evaluation required and the treatment options available, referral of patients with PAH to a specialized center should be considered.
ÎDetermining right and left ventricular function by cardiac catheterization is necessary to make the diagnosis.
> Echocardiography, the most commonly used screening tool, provides estimates of pulmonary artery pressure and assessment of cardiac function.
ÎSymptoms of PAH are related to impaired oxygen transport and reduced cardiac output.
> Dyspnea, fatigue, weakness, exertion intolerance, anginal chest pain and syncope are present in PAH but are nonspecific. Evaluation of patients with these symptoms is directed at excluding more common conditions.
ÎSigns of PAH are subtle, and their sensitivity and specificity are unclear, but PAH is associated with certain physical findings (Table 3).
ÎNumerous diagnostic interventions are recommended for confirmation of the presence of PAH. Those with the highest level of evidence are listed in Table 4.
Table 3. Signs of PAH
ÎAccentuated pulmonary component of second heart sound audible at apex
ÎA tricuspid regurgitation murmur (TR)—audible at lower left sternal border, augmented with inspiration
ÎAn early systolic ejection click due to sudden interruption of pulmonary valve opening
ÎA midsystolic ejection murmur caused by turbulent transvalvular pulmonary flow
ÎA palpable left parasternal lift produced by the impulse of the hypertrophied high-pressure right ventricle
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