Which specialist should a patient with pulmonary hypertension see, a cardiologist or a pulmonologist?

Pulmonary Hypertension Specialist Referral

Patients with pulmonary hypertension should be referred to specialized pulmonary hypertension centers with multidisciplinary teams that include BOTH cardiologists and pulmonologists, not to either specialist alone. 1, 2

Why Not Just One Specialist?

The answer is neither cardiologist alone nor pulmonologist alone—pulmonary hypertension requires a multidisciplinary team approach at specialized referral centers. 1

Required Team Composition

The ESC/ERS guidelines explicitly state that referral centers must provide care through an interprofessional team that includes at minimum: 1

• Two consultant physicians (normally from either or both cardiology and respiratory medicine) with special interest in PH 1
• Clinical nurse specialist 1
• Radiologist with expertise in PH imaging 1
• Cardiologist or PH physician with expertise in echocardiography 1
• Cardiologist or PH physician with expertise in right heart catheterization and vasoreactivity testing 1
• Access to psychological and social work support 1

Why Both Specialties Are Essential

Cardiologists are needed for: 1

• Right heart catheterization expertise (mandatory for diagnosis) 1
• Echocardiography interpretation 1
• Management of right ventricular failure 3
• Vasoreactivity testing 1

Pulmonologists are needed for: 1

• Differential diagnosis of lung disease-related PH (Group 3) 1
• Pulmonary function testing interpretation 1
• Ventilation/perfusion scan interpretation 1
• Management of underlying lung pathology 1

Minimum Center Requirements

A qualified PH referral center must: 1

• Follow at least 50 patients with PAH or CTEPH 1
• Receive at least two new referrals per month with documented PAH or CTEPH 1
• Perform at least 20 vasoreactivity tests per year 1
• Have established networks with genetics, connective tissue disease specialists, pulmonary endarterectomy surgeons, and lung transplantation services 1

Critical Pitfall to Avoid

Do not refer to a single specialist (cardiologist or pulmonologist) in isolation. 2 PH is too complex and requires expertise from both specialties working together at a specialized center. 2, 4 Referral to non-specialized providers can delay appropriate diagnosis and treatment, particularly since right heart catheterization (requiring cardiology expertise) is mandatory before initiating any PAH-specific therapy. 5

When to Refer

Urgent referral to a specialized PH center is indicated when: 6

• Patient has syncope 6
• Rapidly progressing symptoms 6
• Signs of heart failure 6
• Echocardiogram shows elevated pulmonary pressures without confirmed left heart or lung disease 7, 6