title: High prevalence of occult pulmonary venous hypertension revealed by fluid challenge in pulmonary hypertension.
abstract: BACKGROUND
  Determining the cause for pulmonary hypertension is difficult in many patients. Pulmonary arterial hypertension (PAH) is differentiated from pulmonary venous hypertension (PVH) by a wedge pressure (PWP)>15 mm Hg in PVH. Patients undergoing right heart catheterization for evaluation of pulmonary hypertension may be dehydrated and have reduced intravascular volume, potentially leading to a falsely low measurement of PWP and an erroneous diagnosis of PAH. We hypothesized that a fluid challenge during right heart catheterization would identify occult pulmonary venous hypertension (OPVH).
  
  
  RESULTS
  We reviewed the results of patients undergoing fluid challenge in our pulmonary hypertension database from 2004 to 2011. Baseline hemodynamics were obtained and repeated after infusion of 0.5 L of normal saline for 5 to 10 minutes. Patients were categorized as OPVH if PWP increased to >15 mm Hg after fluid challenge. Baseline hemodynamics in 207 patients met criteria for PAH. After fluid challenge, 46 patients (22.2%) developed a PWP>15 mm Hg and were reclassified as OPVH. Patients with OPVH had a greater increase in PWP compared with patients with PAH, P<0.001, and their demographics and comorbid illnesses were similar to patients with PVH. There were no adverse events related to fluid challenge.
  
  
  CONCLUSIONS
  Fluid challenge at the time of right heart catheterization is easily performed, safe, and identifies a large group of patients diagnosed initially with PAH, but for whom OPVH contributes to pulmonary hypertension. These results have implications for therapeutic trials in PAH and support the routine use of fluid challenge during right heart catheterization in patients with risk factors for PVH.
authors.affiliation: Division of Allergy, Pulmonary and Critical Care Medicine and Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC.
authors.forename: Ivan M
authors.initials: IM
authors.lastname: Robbins
authors.forename: Anna R
authors.initials: AR
authors.lastname: Hemnes
authors.forename: Meredith E
authors.initials: ME
authors.lastname: Pugh
authors.forename: Evan L
authors.initials: EL
authors.lastname: Brittain
authors.forename: David X
authors.initials: DX
authors.lastname: Zhao
authors.forename: Robert N
authors.initials: RN
authors.lastname: Piana
authors.forename: Pete P
authors.initials: PP
authors.lastname: Fong
authors.forename: John H
authors.initials: JH
authors.lastname: Newman
mesh_terms: D000328:Adult; D000368:Aged; D006328:Cardiac Catheterization / Q000379:methods*; D015331:Cohort Studies; D003681:Dehydration / Q000628:therapy; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control*; D065627:Familial Primary Pulmonary Hypertension; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects / Q000379:methods*; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D006976:Hypertension, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011669:Pulmonary Wedge Pressure / Q000502:physiology*; D012189:Retrospective Studies; D012307:Risk Factors
keywords: hemodynamics; hypertension, pulmonary; pulmonary arterial hypertension; pulmonary heart disease