In a patient with ischemic heart disease and concentric left ventricular (LV) remodeling, does this cause moderate pulmonary hypertension?

Yes, ischemic heart disease with concentric left ventricular remodeling commonly causes moderate pulmonary hypertension through passive backward transmission of elevated left-sided filling pressures.

Pathophysiologic Mechanism

Ischemic heart disease with concentric LV remodeling directly causes pulmonary hypertension (Group 2 PH-LHD) through a well-established pathophysiologic cascade. 1, 2

• Concentric LV remodeling (relative wall thickness >0.45) results in severe diastolic dysfunction with impaired relaxation and elevated filling pressures 1, 3
• Coronary artery disease is specifically listed as a clinical feature favoring the diagnosis of LV diastolic dysfunction in the presence of pulmonary hypertension 1
• The elevated LV end-diastolic pressure transmits retrograde passively through the left atrium into the pulmonary venous circulation, raising pulmonary capillary wedge pressure (PCWP >15 mmHg) 2, 4, 5
• Up to 60-70% of patients with isolated diastolic dysfunction develop pulmonary hypertension as a complication 2, 6

Clinical Evidence Supporting Causation

The European Society of Cardiology guidelines explicitly identify this relationship:

• Concentric remodeling of the LV (relative wall thickness >0.45) is listed as an echocardiographic factor favoring diagnosis of left ventricular diastolic dysfunction in the presence of pulmonary hypertension 1
• Ischemic heart disease causes myocardial ischemia or MI, which results in heart failure with progressive contractile dysfunction and diastolic impairment 1
• Patients with preserved systolic function and LV hypertrophy are particularly susceptible to acute pulmonary edema episodes because of their reduced ventricular distensibility, where small changes in ventricular volume lead to large changes in filling pressures 1

Prognostic Implications

The presence of moderate pulmonary hypertension in this setting carries substantial prognostic significance:

• Mortality rate after 28 months of follow-up was 57% in patients with moderate PH compared with 17% in patients without PH 1
• Pulmonary hypertension is a poor prognostic marker for patients with chronic heart failure 1
• Patients who have a PVR exceeding 6-8 Wood units have an increased risk of post-operative RV failure following heart transplantation 1

Diagnostic Confirmation Required

To establish this causal relationship definitively:

• Right heart catheterization with measurement of PCWP and LV end-diastolic pressure is essential to confirm that elevated left-sided filling pressures are the cause 1, 2, 6
• PCWP >15 mmHg confirms post-capillary pulmonary hypertension secondary to left heart disease 1, 2, 5
• Doppler echocardiography can suggest elevated LV filling pressures by showing left atrial enlargement, characteristic mitral flow patterns, and LV hypertrophy 1

Management Strategy

The optimal treatment of the underlying left heart disease is recommended in patients with PH due to left heart disease (Class I recommendation, Level C evidence) 1

Evidence-Based Therapeutic Approach:

• Aggressive volume management with diuretics to reduce left ventricular filling pressures and pulmonary venous congestion 1, 2, 6
• Blood pressure control and afterload reduction with ACE inhibitors or ARBs to prevent and potentially reverse left ventricular hypertrophy 1, 2, 6
• Beta-blockers to optimize diastolic filling time and prevent tachyarrhythmias 2, 6
• Optimal treatment of ischemic heart disease including revascularization when appropriate 1

Critical Contraindication:

The use of PAH-specific drug therapy is NOT recommended in patients with PH due to left heart disease (Class III recommendation, Level C evidence) 1

• Randomized controlled trials of epoprostenol and bosentan in advanced heart failure were terminated early due to increased adverse events in the investigational drug-treated group 1, 6
• This represents a critical pitfall: misdiagnosing PH-LHD as pulmonary arterial hypertension and initiating PAH-specific therapy causes patient harm 6

Common Clinical Pitfall

A critical error is overlooking diastolic dysfunction as the primary cause when left ventricular systolic function appears normal—the concentric remodeling pattern specifically indicates diastolic dysfunction even with preserved ejection fraction 3, 2, 6