Pulmonary hypertension, how to diagnose and who to treat?

Pulmonary arterial hypertension is a fatal disease with an estimated survival rate of only 50% after 5 years [1]. Over the last years, knowledge in the field of pulmonary hypertension has grown consistently and significantly. New diagnostic tools, as well as the efficacy of new medications and drug combinations, have been described. How to define and diagnose pulmonary arterial hypertension is the first important issue. Should echocardiography be the method of choice? It is easy to access, cheap and noninvasive. However, the cutoff values are debatable. In the ESC guidelines of 2009 [2] an estimated peak pulmonary artery pressure of >50 mmHg is stated as 'pulmonary hypertension is likely', while a PAP of 37–50 is defined as 'possible PH'. However, the gold standard remains heart catheterisation. Now the definition is made using a mean pulmonary artery pressure of 25 mmHg or more. Age and gender seem to have an important impact on the incidence and severity of PH. For instance, female patients with an atrial septal defect do present with pulmonary hypertension, while in male ASD patients pulmonary hyper-tension is seldom if ever seen. In order to simplify the clinical management of patients, the classification of pulmonary hypertension was changed in 2009 [3]. Pre-capillary PH is defined as a wedge pressure <15 mmHg and can be divided into pulmonary arterial hypertension, PH due to lung disease, chronic thromboembolic PH or PH with unclear and/or multifactorial mechanisms. Post-capillary PH is defined as a wedge pressure above 15 mmHg and is due to left-sided heart disease. Who should be screened for pulmonary hypertension? Should all patients undergoing non-cardiac surgery by tested? Echocardiography and certainly heart catheterisa-tion are not routinely performed, but when complications arise postoperatively, pulmonary hypertension is not seldom detected and although the underlying cause may vary, the prognosis is unfavourable. One could argue that echocardiography screening preoperatively in patients over the age of 60 years may detect high-risk patients for general surgery. Patients known with pulmonary hypertension should be counselled against surgery, or if it is decided to proceed with surgery a team of surgeons, anaesthetists, intensivists and others should make a treatment plan for optimal perioperative care. Advances in treatment of pulmonary arterial hyperten-sion over the past 15 to 20 years have dramatically reduced the morbidity and mortality of the disease. A reduction of 43% in mortality and 61% in hospitalisations was found in a recent meta-analysis [4]. However …