From the Guidelines
Pre-and post-capillary pulmonary hypertension refers to a combined form of pulmonary hypertension where there are abnormalities in both the pre-capillary pulmonary arteries and the post-capillary pulmonary veins, characterized by a mean pulmonary arterial pressure (mPAP) >20 mm Hg, pulmonary arterial wedge pressure (PAWP) >15 mm Hg, and pulmonary vascular resistance (PVR) ≥3 Wood units. This condition is a result of left heart disease causing post-capillary hypertension, which can lead to secondary changes in the pulmonary arteries, resulting in additional pre-capillary hypertension 1. The diagnosis of this combined form is made through right heart catheterization, which shows both elevated PAWP and an elevated PVR 1.
Key Characteristics
- Elevated mPAP >20 mm Hg
- Elevated PAWP >15 mm Hg
- Elevated PVR ≥3 Wood units
- Often occurs in patients with left heart disease, such as heart failure or mitral valve disease
Diagnosis and Treatment
The diagnosis of pre-and post-capillary pulmonary hypertension is crucial, as it may respond differently to treatments than pure pre-capillary or post-capillary hypertension 1. Treatment focuses on addressing the underlying left heart disease with appropriate medications, while also potentially considering pulmonary vasodilators in selected cases. According to the 2018 updated clinical classification, this combined form is characterized by mPAP >20 mm Hg, PAWP >15 mm Hg, and PVR ≥3 Wood units, and is often classified as group 2 or 5 pulmonary hypertension 1.
Importance of Recognition
Recognizing pre-and post-capillary pulmonary hypertension is essential, as it can have a significant impact on patient outcomes, including morbidity, mortality, and quality of life 1. By understanding the characteristics and diagnosis of this combined form, healthcare providers can develop effective treatment plans to improve patient outcomes.
From the Research
Definition of Pre- and Post-Capillary Pulmonary Hypertension
- Pre-capillary pulmonary hypertension is defined as a mean pulmonary arterial pressure ≥25 mmHg at rest with a pulmonary wedge pressure ≤15 mmHg 2.
- Post-capillary pulmonary hypertension is defined as a mean pulmonary arterial pressure ≥25 mmHg at rest with a pulmonary wedge pressure >15 mmHg 2.
Characteristics of Pre- and Post-Capillary Pulmonary Hypertension
- Pre-capillary pulmonary hypertension is often seen in idiopathic pulmonary arterial hypertension (IPAH) 3.
- Post-capillary pulmonary hypertension is often seen in heart failure with preserved ejection fraction (HFpEF) 3.
- Patients with heart failure can develop both pre- and post-capillary pulmonary hypertension, known as combined pre- and post-capillary pulmonary hypertension 4, 5.
Clinical Implications of Combined Pre- and Post-Capillary Pulmonary Hypertension
- Combined pre- and post-capillary pulmonary hypertension is associated with adverse cardiac events and poor clinical outcomes 5.
- The management of combined pre- and post-capillary pulmonary hypertension in advanced heart failure with reduced ejection fraction remains a challenge, but the use of PH-specific therapies and mechanical circulatory devices may be beneficial 6.
- Patients with combined pre- and post-capillary pulmonary hypertension may require individualized treatment approaches, taking into account the underlying mechanisms and severity of the disease 4.