Pulmonary Hypertension is pretty common in hospitalized patients.
On Exam:
- JVP: may have a prominent "A" wave from right ventricular hypertrophy, "CV" waves from tricuspid regurgitation, and Kussmaul's sign along with Hepato-jugular reflux with right ventricular failure.
- General Inspection: You may see a pulsatile RUQ from hepatic congestion
- Precordial Exam: feel for a palpable P2 at the left second intercostal space. In addition, feel for a right ventricular heave. Heart sounds include a louder P2. S2 can be split pretty wide early on. You may also hear a right sided S3 in RV overload, or a right sided S4 with RV hypertrophy.
- Tricuspid Regurgitation: this is often a higher pitch, holosystolic murmur that is best heard at the left (sometimes right sternal border), and if heard on the left side may radiate to the right.
- Special tests with Tricuspid Regurgitation: Increasing venous return will accentuate the murmur (eg. push on liver, passive leg raise), while decreasing venous return (eg. go from sit to stand) will decrease the murmur. Watch for TR to be accentuated during inspiration....this is called Carvallo's sign.
- Other: look for cyanosis centrally and peripherally, and a pulsus paridoxus. Often you will be able to feel a pulsatile liver edge, and peripheral edema is common.
A good approach to the etiology of Pulmonary Hypertension....think of pre-capillary, capillary, and post-capillary causes:
Precapillary:
- chronic thrombotic or embolic disease, pulmonary emboli, sickle cell disease
Capillary/Parenchymal
- Obstructive Lung Disease: COPD
- Interstitial Lung Disease
- Restrictive Lung Disease: chest wall or neuromuscular problems
- Obstructive Sleep Apnea
- Connective Tissue Disease: scleroderma (common), RA and SLE (rare)
- Vasculitis: eg Wegeners
- HIV
- Medications/drugs like diet pills (fenfen), herbs (bush tea in some areas - Jamaica), cocaine, amphetamines
Post Capillary:
- Left Ventricular Issues: LVH, shunts, mitral or aortic valvular dysfunction
- Constrictive pericarditis
- Mediastinal fibrosis
Some Good Links:
Here a good review from NEJM on Pulmonary Hypertension, and an easy to read summary from JAMA.
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