Predicting pulmonary hypertension and outcomes in patients with left heart disease

Doctoral Thesis


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University of Cape Town

Pulmonary hypertension (PH) is defined as a rise in the pressure in the pulmonary arteries resulting from a variety of diseases including chronic infectious diseases, lung diseases and left heart diseases (LHD). It is a global health problem and accounts for a substantial portion of cardiovascular disease. PH due to LHD (PH-LHD) is credited to be the most common form of PH worldwide and is associated with adverse outcomes. Considering the suggestions of high prevalence and potential adverse outcomes of PH in sub-Saharan Africa (SSA), the investigation of the etiologies, clinical profile, correlates, and outcomes of PH-LHD in this region is a medical priority. Methods: Through a systematic review, we assessed existing evidence on the predictors of PH-LHD outcomes. Then, through two prospective multinational cohort registries, we investigated 1) the spectrum of PH in SSA; 2) the clinical profile and 6 months outcome of PH-LHD; 3) the role of electrocardiogram for diagnosing PH and 4) its prognostic role in heart failure (HF). PH was diagnosed by echocardiography in the context of clinical suspicion. Results: In high income countries, PH-LHD is almost invariably associated with increased mortality risk, but the effects on hospitalization are yet to be fully characterized. All groups of PH are found in SSA with LHD being the major cause. PH-LHD affects young people and is predominantly due to HF and rheumatic valvular heart disease. In these patients, left atrium size and tricuspid annular plan excursion are predictors of pulmonary pressures, and PH-LHD predicts short term hospitalization but not mortality. A normal electrocardiogram is very rare in patients with PH, but electrocardiogram criteria of right ventricular strain are rather rare and non-specific. Similarly, electrocardiogram abnormalities are frequent among Africans with HF, some have prognostic value for mortality risk. Conclusion: PH-LHD is the most common form of PH in SSA, with affected patients presenting with advanced disease, and it is associated with adverse outcomes. ECG abnormalities are prevalent in both PH and HF, but few of these abnormalities have prognostic value for mortality risk. Evaluating the efficacy and safety of low-cost and available drugs in reducing HF hospitalizations in PH-LHD is a key future priority. Improving early diagnosis of PH should also be encouraged.

Includes bibliographical references