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Pulmonary Hypertension Dx after PE?
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Pulmonary Hypertension Dx after PE?

In February, a few days after minor outpatient surgery to fix an ankle (tibia) fracture, I began feeling as though the air I was breathing wasn't doing me much good. A ventilation/perfusion lung scan revealed a massive pulmonary embolism, and I was hospitalized on 4 liters of oxygen and IV heparin.

An echocardiograph resulted in the following report:
pulmonary arterial pressures severely elevated (67);
pulmonary artery was very enlarged;
right atrium and ventricle severely enlarged and impinging on left heart size and function;
ventricular wall enlarged;
mild dysynchrony between right and left heart;
significant valvular regurgitation

The pulmonologist, after consultation with a cardiologist, indicated that my heart was strained beyond what should have been its maximum physiologic capacity for an acute episode of PE. The docs said that there must have been some pulmonary hypertension prior to the episode that allowed my heart to acclimate to the pressure.

I was given systemic thrombolytics. A few days later I was able to go off oxygen. A follow-up V/Q scan showed improved but still significant clots, and possibly areas of pulmonary infarction. I felt a lot better, though. I was discharged on warfarin.

About seven weeks after the episode I had a follow-up echo. It showed a reduced but still elevated pap (48), enlarged right atrium and ventricle, and tricuspid regurgitation;  other signs of right ventricular dysfunction were greatly diminished.

The pulmonologist wants to see me for some pulmonary function tests in August, after another echo. She said that we would wait till then to explore what might have caused elevated pressures prior to the acute episode of PE.

As far as symptoms go, I currently experience some sob and lightheadedness after strenuous effort, but I can go about my daily business and exercise. It's hard to tell the difference between "symptoms" and the natural consequences of being very fat. (I'm a woman, 37, 5'2" and - yikes! - 270lbs.)

Here are my questions. Is evidence of elevated pulmonary arterial pressures tantamount to a diagnosis of pulmonary hypertension? Should I be evaluated by a PH specialist? Is it even possible to evaluate PH a few months post-acute PE? Should I ask for a right heart cath? Should CCBs be considered at this point? If it's CTEPH, when should thromboendarterectomy be considered? Should I just sit tight till August? Also, I am now lifting weights, swimming, biking, rowing and making a laughable effort at Tae Bo as part of my weight loss efforts. I rest when I get dizzy or sob, and then continue. That won't do me any harm, will it? Thanks.

Benigna




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Avatar_n_tn
Dear Benigna,
These are good questions and ones that you should address with the pulmonologist.  I can give you a "cardiologists view" of pulmonary hypertension but it may not be the complete story.  Elevated pulmonary pressures are not the same thing as the disease pulmonary hypertension.  Many different things (including pulmonary embolism 'PE') can lead to elevated pressures.  After these other causes have been excluded the diagnosis of 'primary pulmonary hypertension' can be made.  As far as seeing a specialist in PH I would ask your doctor what her experience in treating PH has been.  If she has a good deal of experience and can offer all treatments including iv prostacyclins and lung transplant (if needed) then I would stick with her.  Otherwise you may wish to ask for a referral to a larger medical center.  The right heart cath and treatment decisions are best left to your doctor who can evaluate all of the data and options.  It sounds like your doctor wants to wait until you are a bit further out from this acute episode of PE before making further decisions which does not sound unreasonable to me.  If however you are worsening I would try to see her sooner.  The exercise is probably OK but your doctor should give you the final clearance.  Best wishes to you.
2 Comments
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Avatar_n_tn
I am no dr but i am also concerned about deveoling PPH due to a hole in my ventrical. My pressures by echo are 33 %. I have read alot on it and from what i gather, you definately need a PH specialist ASAP!! The cleveland heart book says that most cardiologist dont even pay close attention to those readings.
You also sound like you have conciderable changes in heart size and i would reccomend getting into a cardiac rehab program so you can be closly monitored while exercising. With your conciderable size ( i am also over wieght) you should be more careful about heavy duty activiy. Your body including you heart is not used to all that. Start out with walking and let your heart get used to it first. Get into cardiac rehab so they can tell what happens when you exercise.
  Good luck to you.
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