History
Symptoms of pulmonary hypertension due to left-sided heart disease (PH-LHD) can be nonspecific and progressive. The medical history can reveal a previous diagnosis of myocardial infarction, cardiomyopathy from systolic or diastolic dysfunction, congenital cardiomyopathies or inflow or outflow tract obstruction, systemic arterial hypertension, or pericarditis.
Symptoms include the following:
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Dyspnea
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Weakness
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Fatigue
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Syncope with exertion due to poor cardiac output response to increased activity
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Lower extremity swelling from an increase in right-sided filling pressure
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Hoarseness (Ortner syndrome) from compression of the recurrent laryngeal nerve by an enlarged pulmonary artery
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Right upper quadrant pain or abdominal swelling from hepatic venous congestion
Physical Examination
Examination of patients with pulmonary hypertension due to left-sided heart disease (PH-LHD) may initially reveal findings consistent with left ventricular heart failure or valvular dysfunction. As the disease progresses, patients demonstrate signs of worsening right-sided heart dysfunction.
Physical examination findings consist of the following:
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Pulmonary crackles in the presence of volume overload
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S3 or S4 heart sounds
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Increased S2 heart sound intensity with development of splitting of S2 sound from right ventricular failure
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Right ventricular heave
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Elevated jugular venous pulse from volume overload with prominent A wave
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Hepatomegaly with hepatic vessel pulsations from hepatic venous congestion
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Ascites in the presence of right-sided heart failure
Complications
Group 2 pulmonary hypertension is associated with a higher morbidity and mortality when compared with patients with left-sided heart disease alone. Long-term complications include the development of right ventricular failure.
Complications of pulmonary hypertension due to left-sided heart disease (PH-LHD) include the following:
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Right ventricular failure
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Ascites
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Pleural effusion
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Peripheral extremity edema
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Hoarseness
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Syncope
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Chest radiograph of a patient with pulmonary hypertension due to left-sided heart disease from heart failure with reduced ejection fraction showing enlarged pulmonary arteries, mild pulmonary vascular congestion, and dilated right atrium and left atrium.
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Transthoracic echocardiograph showing an apical four-chamber view of the same patient with pulmonary hypertension due to heart failure with reduced ejection fraction. The right atrium and ventricle are notably dilated.
