What is the next step in treatment for a 71-year-old male with shortness of breath (SOB), a history of percutaneous coronary intervention (PCI) in 1997, normal stress echocardiogram results, enlarged left and right atrial chamber dimensions, and elevated pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 58 mmHg?

From the Guidelines

The next step in treatment for this 71-year-old male with shortness of breath, history of PCI, and evidence of pulmonary hypertension (PASP 58 mmHg) with bilateral atrial enlargement should be a comprehensive evaluation to determine the underlying cause of his pulmonary hypertension, as recommended by the 2014 Chest guideline and expert panel report on pharmacologic therapy for pulmonary arterial hypertension in adults 1. This evaluation should include a right heart catheterization to confirm the diagnosis and classify the type of pulmonary hypertension.

• Additional testing should include:
  • Pulmonary function tests
  • Ventilation-perfusion scan
  • Chest CT
  • Sleep study to rule out common causes such as COPD, pulmonary embolism, interstitial lung disease, and sleep apnea
• Laboratory tests for connective tissue diseases, HIV, and liver disease should also be performed. Once the etiology is determined, specific therapy can be initiated.
• If left heart disease is confirmed as the cause (given his cardiac history), treatment would focus on optimizing heart failure therapy with medications like ACE inhibitors/ARBs, beta-blockers, diuretics, and possibly aldosterone antagonists.
• For patients with pulmonary arterial hypertension, specific vasodilator therapies such as phosphodiesterase-5 inhibitors (sildenafil), endothelin receptor antagonists (bosentan), or prostacyclin analogs may be indicated, as discussed in the 2014 Chest guideline 1. Supplemental oxygen should be provided if hypoxemia is present. This approach is necessary because pulmonary hypertension treatment must target the underlying cause rather than just the elevated pressures themselves, as emphasized in the 2014 Chest guideline and expert panel report 1.

From the FDA Drug Label

Sildenafil tablets are a prescription medicine used in adults to treat pulmonary arterial hypertension (PAH). With PAH, the blood pressure in your lungs is too high. Your heart has to work hard to pump blood into your lungs. Sildenafil tablets improve the ability to exercise and can slow down worsening changes in your physical condition

The patient has pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 58 mmHg. The next step in treatment could be to consider sildenafil tablets, as they are used to treat pulmonary arterial hypertension (PAH) in adults. However, it is crucial to note that the patient had a PCI in 1997, and sildenafil tablets should not be taken with nitrate medicines, which are often used to treat angina. Therefore, it is essential to review the patient's current medication list and medical history before initiating sildenafil tablets. The patient should be advised to take sildenafil tablets exactly as prescribed by their doctor, typically 3 times a day, and to report any side effects, such as low blood pressure. 2

From the Research

Treatment Options for Pulmonary Arterial Hypertension (PAH)

The patient's diagnosis of PAH with an estimated pulmonary arterial systolic pressure of 58 mmHg requires careful consideration of treatment options. The following points summarize the potential next steps in treatment:

• The use of oral combination therapy, such as bosentan and sildenafil, has been shown to be safe and effective in patients with PAH 3.
• Bosentan added to sildenafil therapy has been investigated in several studies, with mixed results. One study found that adding bosentan to sildenafil did not delay the time to the first morbidity/mortality event 4, while another study found that sildenafil dosed concomitantly with bosentan did not improve 6-minute walk distance compared to placebo 5.
• Other treatment options for PAH include endothelin-receptor antagonists, phosphodiesterase inhibitors, and prostacyclin analogues. A treatment algorithm for PAH suggests that patients with mild to moderate symptoms may be treated with oral therapies such as sildenafil and bosentan, while patients with moderate to severe PAH may require infusions of prostacyclin analogues 6.
• Diuretics, such as furosemide, may also be used to manage symptoms of PAH, particularly in patients with right atrial chamber dimension enlargement and elevated pulmonary hypertension 7.

Potential Next Steps

Based on the patient's diagnosis and the available evidence, potential next steps in treatment may include:

• Initiating oral combination therapy with bosentan and sildenafil, or adding bosentan to existing sildenafil therapy.
• Considering alternative treatment options, such as endothelin-receptor antagonists or prostacyclin analogues, depending on the patient's symptoms and disease severity.
• Using diuretics, such as furosemide, to manage symptoms of PAH and reduce right atrial chamber dimension enlargement.