Left ventricular heart failure and pulmonary hypertension.
In patients with left ventricular heart failure (HF), the development of pulmonary hypertension (PH) and right ventricular (RV) dysfunction are frequent and have important impact on disease progression, morbidity, and mortality, and therefore warrant clinical attention. Pulmonary hypertension related to left heart disease (LHD) by far represents the most common form of PH, accounting for 65-80% of cases. The proper distinction between pulmonary arterial hypertension and PH-LHD may be challenging, yet it has direct therapeutic consequences. Despite recent advances in the pathophysiological understanding and clinical assessment, and adjustments in the haemodynamic definitions and classification of PH-LHD, the haemodynamic interrelations in combined post- and pre-capillary PH are complex, definitions and prognostic significance of haemodynamic variables characterizing the degree of pre-capillary PH in LHD remain suboptimal, and there are currently no evidence-based recommendations for the management of PH-LHD. Here, we highlight the prevalence and significance of PH and RV dysfunction in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), and provide insights into the complex pathophysiology of cardiopulmonary interaction in LHD, which may lead to the evolution from a 'left ventricular phenotype' to a 'right ventricular phenotype' across the natural history of HF. Furthermore, we propose to better define the individual phenotype of PH by integrating the clinical context, non-invasive assessment, and invasive haemodynamic variables in a structured diagnostic work-up. Finally, we challenge current definitions and diagnostic short falls, and discuss gaps in evidence, therapeutic options and the necessity for future developments in this context.
Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937 Köln, Germany Cologne Cardiovascular Research Center (CCRC), Universität zu Köln, Köln, Germany stephan.rosenkranz@uk-koeln.de.
Stephan
S
Rosenkranz
National Heart and Lung Institute (NHLI), Imperial College London, London, UK Department of Cardiology, National Pulmonary Hypertension Service, Hammersmith Hospital London, London, UK.
J Simon R
JS
Gibbs
Klinik für Kardiologie und Pneumologie, Herzzentrum, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Germany German Cardiovascular Research Center (DZHK), Göttingen, Germany.
Rolf
R
Wachter
Division of Cardiology, University of California San Francisco (UCSF), San Francisco, CA, USA.
Teresa
T
De Marco
Department of Pneumology, VU University Medical Center, Amsterdam, The Netherlands.
Anton
A
Vonk-Noordegraaf
Department of Cardiology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
Jean-Luc
JL
Vachiéry
D006333:Heart Failure / Q000150:complications* / Q000503:physiopathology / Q000628:therapy; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D006976:Hypertension, Pulmonary / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D008944:Mitral Valve Insufficiency / Q000601:surgery; D010641:Phenotype; D011652:Pulmonary Circulation / Q000502:physiology; D018487:Ventricular Dysfunction, Left / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy
Heart failure; Post-capillary; Pre-capillary; Pulmonary hypertension