Hemodynamic Classification of This Patient
Yes, these hemodynamic values are consistent with Group 2 pulmonary hypertension (PH due to left heart disease), specifically isolated post-capillary PH. 1
Hemodynamic Analysis
Your patient's values meet the diagnostic criteria for post-capillary PH:
- Mean PA pressure of 28 mmHg meets the threshold for PH (≥25 mmHg by 2015 guidelines, ≥20 mmHg by newer definitions) 2
- PCWP of 16 mmHg is elevated (>15 mmHg), which is the critical distinguishing feature that defines post-capillary PH 1, 2
- Cardiac output of 2.98 L/min is reduced, indicating compromised cardiac function 1
Calculating Pulmonary Vascular Resistance
To definitively classify this as isolated versus combined post-capillary PH, you must calculate PVR:
PVR = (mPAP - PCWP) / CO = (28 - 16) / 2.98 = 4.03 Wood units 3
This PVR of 4.03 Wood units is >3 Wood units, which technically meets criteria for combined post-capillary and pre-capillary PH (Cpc-PH) rather than isolated post-capillary PH 1, 2. This indicates superimposed pulmonary vascular disease with vasoconstriction and remodeling beyond passive congestion alone 1.
Clinical Significance
Combined post-capillary and pre-capillary PH carries worse prognosis than isolated post-capillary PH 1. The diastolic pressure gradient (DPG) provides additional prognostic information:
- DPG = diastolic PAP - mean PCWP 2
- If DPG ≥7 mmHg, this confirms Cpc-PH and is associated with increased mortality 1
Diagnostic Workup Required
To confirm Group 2 PH, look for these clinical features that strongly suggest left heart disease rather than other PH groups 1:
- Age >65 years
- Symptoms of left heart failure (orthopnea, paroxysmal nocturnal dyspnea)
- Features of metabolic syndrome
- History of coronary artery disease, hypertension, or valvular disease
- Persistent atrial fibrillation
Echocardiographic findings supporting Group 2 PH include 1:
- Structural left heart abnormality
- Doppler indices of increased LV filling pressures
- Bowing of inter-atrial septum to the right
Management Approach
The primary treatment goal is optimizing management of the underlying left heart disease 1, 4, 5. This includes:
- Aggressive heart failure therapy with guideline-directed medical therapy 5
- Repair of valvular disease when indicated 1
- Optimizing volume status 1
- Controlling cardiovascular risk factors 1
Critical caveat: PAH-specific therapies (phosphodiesterase-5 inhibitors, endothelin receptor antagonists, prostacyclin analogues) are not indicated for Group 2 PH and should only be used for Group 1 PAH 4, 5. Current data for these agents in post-capillary PH remain limited and conflicting 5.
Common Pitfalls to Avoid
- Do not rely on echocardiography alone for hemodynamic classification—right heart catheterization remains the gold standard 1
- Ensure accurate PCWP measurement by zeroing the transducer at mid-thoracic line and measuring at end-expiration during spontaneous breathing 3
- Consider direct left atrial pressure measurement if PCWP seems inaccurate or if there is clinical-hemodynamic discrepancy 3
- Recognize that elevated PCWP alone may not always indicate left heart disease—consider calculating transmural pressure difference (PCWP - RAP) for additional diagnostic accuracy 6