Approach Considerations
Treatment for group 2 pulmonary hypertension consists primarily of treating the underlying left-sided heart disease. Treatment can include pharmacotherapies, surgery, or minimally invasive techniques (valve replacements, bypass grafting, assist devices). [13]
Surgical Care
In cases of left-sided sided disease due to valvular disease (aortic or mitral), consideration should be made for referral to a cardiothoracic surgeon for valve repair. For left-sided disease refractory to medical therapy, heart transplantation should be considered.
Consultations
Referral to a center that specializes in pulmonary hypertension is recommended for further management. With underlying left-sided heart disease, it is recommended to consult with a cardiologist to help with management. In cases of refractory left-sided heart disease, consideration must be made for a referral for cardiac transplantation.
Diet
Currently, there are no direct guidelines regarding diet for group 2 pulmonary hypertension. However, conservative fluid intake (< 1.5-2 L/day) and avoiding excess salt intake (< 3 g/day) are recommended to prevent exacerbation of left-sided heart disease. Additionally, in cases of left-sided disease due to an ischemic etiology, avoidance of foods high in fats and cholesterol is recommended to prevent further worsening of underlying coronary artery disease.
Activity
Patients with group 2 pulmonary hypertension can continue to remain active and to partake in physical activity as tolerated; however, very strenuous activity can worsen symptoms.
Prevention
In cases of left-sided disease due to hypertension, avoidance of high salt intake and optimization of blood pressure can prevent worsening of underlying disease. Additionally, patients should take preventative measures to avoid foods high in cholesterol and fats if the underlying etiology is coronary artery disease. Patients should receive their pneumococcal vaccination and annual influenza vaccination.
Long-Term Monitoring
Patients should see their pulmonary hypertension specialist regularly. A 6-minute walk test (6MWT) is performed at regular intervals to evaluate functional status. Patients should have a transthoracic echocardiography performed at least annually. A significant change in functional status should prompt a repeat echocardiography and/or right-sided heart catheterization.
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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.
