Causes of Low-Grade, Pleuritic, Left-Sided Chest Pain in Pulmonary Hypertension
The most common causes of low-grade, pleuritic, left-sided chest pain in patients with pulmonary hypertension include pulmonary embolism, pulmonary veno-occlusive disease, left heart disease complications, and pleural inflammation. These conditions require careful evaluation as they may significantly impact morbidity and mortality in this vulnerable population.
Pulmonary Embolism
- Pulmonary embolism (PE) is the most common potentially life-threatening cause of pleuritic chest pain, found in 5-20% of patients presenting with this symptom 1
- PE can present with pleuritic chest pain (with or without dyspnea), which is typically due to distal emboli causing pleural irritation 2
- In patients with pulmonary hypertension, recurrent PE can lead to chronic thromboembolic pulmonary hypertension (CTEPH), which requires specific management 2
- PE should be suspected in any patient with pulmonary hypertension who develops new or worsening pleuritic chest pain, especially if accompanied by hypoxemia 2
Pulmonary Veno-Occlusive Disease (PVOD)
- PVOD is a rare but serious cause of pulmonary hypertension that can present with pleuritic chest pain 2
- PVOD is characterized by progressive obstruction of pulmonary veins leading to pulmonary congestion and edema 2
- Radiographic findings include patchy areas of ground-glass opacification, septal lines, and mediastinal lymph node enlargement 2
- PVOD patients may experience pleuritic chest pain due to pleural inflammation from adjacent pulmonary congestion and microinfarcts 2
Left Heart Disease Complications
- Left heart disease is one of the most common causes of pulmonary hypertension in the United States 3
- Patients with pulmonary hypertension due to left heart disease may experience pleuritic chest pain from:
Pleural Inflammation
- Viral or inflammatory pleurisy can occur in patients with pulmonary hypertension, causing pleuritic chest pain 1
- Pleural effusions are common in patients with advanced pulmonary hypertension, especially those with left heart disease 2
- Pleuritic pain may be exacerbated by respiratory movements, coughing, or deep breathing 1
Pneumonia and Other Pulmonary Infections
- Patients with pulmonary hypertension are susceptible to respiratory infections that can cause pleuritic chest pain 1
- Pneumonia with pleural involvement can present with pleuritic chest pain, fever, and cough 1
- Infections should be promptly identified and treated to prevent worsening of pulmonary hypertension 2
Pneumothorax
- Spontaneous pneumothorax can occur in patients with pulmonary hypertension, especially those with underlying lung disease 1
- Presents with sudden-onset pleuritic chest pain and dyspnea 1
- Requires immediate evaluation with chest radiography and prompt management 2
Diagnostic Approach
- History, physical examination, and chest radiography are recommended for all patients with pleuritic chest pain 1
- Electrocardiography is essential, especially if there is clinical suspicion of myocardial infarction, pulmonary embolism, or pericarditis 1
- Echocardiography is indicated in patients with unexplained dyspnea to detect cardiovascular complications 2
- CT imaging may be necessary to evaluate for PVOD, which shows characteristic patterns of ground-glass opacities and septal lines 2
- Ventilation/perfusion scanning is preferred for evaluating suspected pulmonary embolism in patients with pulmonary hypertension 2
Management Considerations
- Treatment should target the underlying cause of pleuritic chest pain while continuing management of pulmonary hypertension 2
- Careful volume management is imperative in patients with right ventricular failure 3
- Avoid hypoxemia and hypercapnia, which can worsen right ventricular function 5
- For patients with PVOD, early referral to a transplant center is indicated as soon as the diagnosis is established 2
- Patients with pulmonary hypertension should be managed in centers with experience in this condition, particularly when complications arise 2