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Original Article

High Prevalence of Occult Pulmonary Venous Hypertension Revealed by Fluid Challenge in Pulmonary HypertensionClinical Perspective

Ivan M. Robbins, Anna R. Hemnes, Meredith E. Pugh, Evan L. Brittain, David X. Zhao, Robert N. Piana, Pete P. Fong, John H. Newman
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https://doi.org/10.1161/CIRCHEARTFAILURE.113.000468
Circulation: Heart Failure. 2014;7:116-122
Originally published January 21, 2014
Ivan M. Robbins
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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Anna R. Hemnes
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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Meredith E. Pugh
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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Evan L. Brittain
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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David X. Zhao
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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Robert N. Piana
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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Pete P. Fong
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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John H. Newman
From the Division of Allergy, Pulmonary and Critical Care Medicine (I.M.R., A.R.H., M.E.P., J.H.N.) and Division of Cardiovascular Medicine (E.L.B., R.N.P., P.P.F.), Vanderbilt University Medical Center, Nashville, TN; and Division of Cardiology, Wake Forest Baptist Medical Center, Winston-Salem, NC (D.X.Z.).
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Abstract

Background—Determining the cause for pulmonary hypertension is difficult in many patients. Pulmonary arterial hypertension (PAH) is differentiated from pulmonary venous hypertension (PVH) by a wedge pressure (PWP) >15 mm Hg in PVH. Patients undergoing right heart catheterization for evaluation of pulmonary hypertension may be dehydrated and have reduced intravascular volume, potentially leading to a falsely low measurement of PWP and an erroneous diagnosis of PAH. We hypothesized that a fluid challenge during right heart catheterization would identify occult pulmonary venous hypertension (OPVH).

Methods and Results—We reviewed the results of patients undergoing fluid challenge in our pulmonary hypertension database from 2004 to 2011. Baseline hemodynamics were obtained and repeated after infusion of 0.5 L of normal saline for 5 to 10 minutes. Patients were categorized as OPVH if PWP increased to >15 mm Hg after fluid challenge. Baseline hemodynamics in 207 patients met criteria for PAH. After fluid challenge, 46 patients (22.2%) developed a PWP >15 mm Hg and were reclassified as OPVH. Patients with OPVH had a greater increase in PWP compared with patients with PAH, P<0.001, and their demographics and comorbid illnesses were similar to patients with PVH. There were no adverse events related to fluid challenge.

Conclusions—Fluid challenge at the time of right heart catheterization is easily performed, safe, and identifies a large group of patients diagnosed initially with PAH, but for whom OPVH contributes to pulmonary hypertension. These results have implications for therapeutic trials in PAH and support the routine use of fluid challenge during right heart catheterization in patients with risk factors for PVH.

  • hemodynamics
  • hypertension, pulmonary
  • pulmonary arterial hypertension
  • pulmonary heart disease
  • Received May 5, 2013.
  • Accepted November 13, 2013.
  • © 2013 American Heart Association, Inc.
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January 2014, Volume 7, Issue 1
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    High Prevalence of Occult Pulmonary Venous Hypertension Revealed by Fluid Challenge in Pulmonary HypertensionClinical Perspective
    Ivan M. Robbins, Anna R. Hemnes, Meredith E. Pugh, Evan L. Brittain, David X. Zhao, Robert N. Piana, Pete P. Fong and John H. Newman
    Circulation: Heart Failure. 2014;7:116-122, originally published January 21, 2014
    https://doi.org/10.1161/CIRCHEARTFAILURE.113.000468

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    High Prevalence of Occult Pulmonary Venous Hypertension Revealed by Fluid Challenge in Pulmonary HypertensionClinical Perspective
    Ivan M. Robbins, Anna R. Hemnes, Meredith E. Pugh, Evan L. Brittain, David X. Zhao, Robert N. Piana, Pete P. Fong and John H. Newman
    Circulation: Heart Failure. 2014;7:116-122, originally published January 21, 2014
    https://doi.org/10.1161/CIRCHEARTFAILURE.113.000468
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