Can a cardiac arrhythmia cause secondary pulmonary hypertension?

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Last updated: October 31, 2026 • View editorial policy

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Can Heart Arrhythmia Lead to Pulmonary Hypertension?

Yes, cardiac arrhythmias can cause secondary pulmonary hypertension, particularly through mechanisms of atrioventricular dyssynchrony and chronic atrial arrhythmias, though this represents a less common and often reversible form of PH.

Mechanism and Clinical Evidence

The 2015 ESC/ERS guidelines classify pulmonary hypertension into five groups, with Group 2 (PH due to left heart disease) being the most common cause of secondary PH 1. While the guidelines don't specifically highlight arrhythmias as a primary mechanism, they note that up to 60-70% of patients with heart failure can develop PH 1.

The most compelling evidence comes from a 2026 case report demonstrating severe, reversible PH triggered by complete heart block: An 86-year-old patient with preserved left ventricular function (LVEF 60%) developed severe PH with pulmonary artery systolic pressure of 120 mmHg due to AV dyssynchrony from complete heart block 2. After pacemaker implantation, the PASP dropped dramatically to 75 mmHg within 24 hours and normalized to 40 mmHg by two weeks 2. This demonstrates that arrhythmia-induced PH can be:

  • Rapidly reversible when the underlying rhythm disturbance is corrected
  • Severe even with preserved systolic function
  • Mediated by AV dyssynchrony causing hemodynamic compromise beyond simple bradycardia

Specific Arrhythmias and Risk

The most relevant arrhythmias include:

  • Atrial fibrillation and flutter - prevalence of 7% and 2% respectively at PAH diagnosis 3
  • Complete heart block - causes severe AV dyssynchrony 2
  • Supraventricular tachycardias - emerging as important outcomes in PH patients 4

Importantly, the relationship is bidirectional: While arrhythmias can cause PH, PH itself predisposes to arrhythmias through right atrial and ventricular structural changes 4. Nearly one-third of PAH patients develop new arrhythmias within 10 years of diagnosis 3.

Clinical Implications and Prognosis

When arrhythmias occur in the context of PH, outcomes worsen significantly:

  • Mortality increases substantially: Patients with arrhythmias before PAH diagnosis have an adjusted hazard ratio of 2.06 for all-cause mortality, while those developing arrhythmias after PAH diagnosis have an HR of 1.57 3
  • Hospitalizations increase: Arrhythmic patients experience shorter time to first hospitalization (9.5-15.9 vs 21.2 months) and more frequent admissions (0.38-0.64 vs 0.10 per year) 3

Diagnostic Clues

Look for diastolic tricuspid regurgitation as a specific marker of arrhythmia-related PH 2. In elderly patients presenting with:

  • Progressive fatigue and orthopnea
  • Preserved systolic function on echo
  • Marked left atrial dilation
  • Right ventricular enlargement
  • Known rhythm disturbances (especially complete heart block or chronic AF)

Consider arrhythmia as a potentially reversible contributor to PH.

Management Approach

Restoration of AV synchrony through pacing or rhythm control is the definitive treatment when arrhythmia is the primary driver 2. The rapid hemodynamic improvement seen with pacemaker implantation (within 24 hours) suggests this should be prioritized in appropriate candidates 2.

Critical Caveat

This represents a rare but important subset of secondary PH. Most PH cases relate to left heart disease from other causes (valvular disease, systolic/diastolic dysfunction) or primary pulmonary vascular disease 1. However, recognizing arrhythmia-mediated PH is crucial because it may be completely reversible with appropriate rhythm management, unlike most other forms of PH.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.