Pulmonary hypertension in the elderly, part 1: Evaluation

Pulmonary hypertension in the elderly, part 1: Evaluation

ABSTRACT: Pulmonary arterial hypertension (PAH) is an increasingly recognized cause of dyspnea in elderly patients. The initial workup typically includes electrocardiography, chest adiography, echocardiography, and pulmonary function tests. If echocardiography shows signs of PAH, the diagnosis should be confirmed by right heart catheterization. Radiographic evidence of long-standing PAH includes enlargement of the central pulmonary arteries with abrupt narrowing of the more distal branches, giving a "pruned-tree" appearance, and right ventricular (RV) enlargement. The classic radiographic signs of RV enlargement include increased transverse diameter of the heart, elevation of the cardiac border on the posteroanterior view, and narrowing or loss of the retrosternal airspace on the lateral projection. (J Respir Dis. 2008;29(11):443-450)

Dyspnea has been defined as a "subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity."1 It is a common complaint that becomes more frequent with age, with an incidence ranging from 17.4% in patients younger than 45 years to 38% in those older than 65 years.1 Dyspnea has been associated with poor perceived health, increased anxiety and depressive symptoms, impaired daily functioning, and reduced happiness. 2 Furthermore, moderate to severe dyspnea was associated with an increased risk of death in a cohort of 124 patients who were older than 70 years.2

Dyspnea is associated with a variety of diagnoses in the elderly, most commonly obstructive lung disease (emphysema, asthma), restrictive lung disease (pulmonary fibrosis), and cardiac disease (congestive heart failure). An aggressive evaluation to determine the cause of dyspnea is necessary. A simple history and physical examination with screening tests can often determine the cause. However, persistent dyspnea despite an extensive evaluation can be puzzling for both the clinician and the patient.

Pulmonary hypertension (PH) has been increasingly recognized as a cause of insidious dyspnea in the elderly and should be added to the differential diagnosis when common causes of this symptom are absent. Advances in recognition, diagnosis, and management of PH have led to earlier intervention and improved prognosis over the past decade. Of course, successful therapy first requires a suspicion for the disease followed by an appropriate evaluation.

In part 1 of this article, we will review the diagnostic evaluation of PH in elderly patients. In part 2, we will focus on management.

Defining PH

PH is defined as a mean pulmonary artery pressure (PAP) of greater than 25 mm Hg.3 It can be an insidious cause of dyspnea and is increasingly discovered as a result of the ease of obtaining a screening echocardiogram.


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