Key clinical features suggesting pulmonary hypertension (PH) in primary care include:
- Dyspnoea on exertion is the most common and important symptom, often progressive and disproportionate to other lung or heart disease.
- Fatigue and limited exercise tolerance frequently accompany dyspnoea, reflecting reduced cardiac output and oxygen delivery.
- Chest pain, typically central and non-pleuritic, may be present due to right ventricular strain or ischaemia.
- Syncope or light-headedness can occur, especially on exertion, indicating advanced disease and compromised cardiac output.
- Signs on examination may include raised jugular venous pressure, a loud pulmonary component of the second heart sound, a right ventricular heave (parasternal systolic impulse), peripheral oedema, and hepatomegaly, reflecting right heart strain or failure.
- Other nonspecific symptoms such as palpitations or cough may be reported but are less specific.
- In patients with underlying conditions like sickle cell disease, these symptoms warrant urgent referral to specialist pulmonary hypertension centres NICE CKS.
- Clinical examination should assess for signs of right heart failure and exclude other causes of dyspnoea,2,NICE CKS,NICE NG115.
In primary care, suspicion of PH should arise when these symptoms and signs are unexplained by more common conditions such as chronic obstructive pulmonary disease, heart failure, or interstitial lung disease, or when symptoms are disproportionate to these diagnoses. Early recognition is critical as PH is often asymptomatic or presents with nonspecific symptoms until advanced stages NICE CKS[Olsson et al. 2023].
Initial investigations in primary care may include pulse oximetry, chest X-ray, ECG, and NT-proBNP measurement to assess for cardiac strain and exclude other causes. Echocardiography is the key diagnostic tool but is usually arranged by secondary care after referral NICE CKS,NICE CKS,NICE CKS[Condliffe et al. 2023].
Key References
- CKS - Sickle cell disease
- CKS - Palliative care - dyspnoea
- CKS - Heart failure - chronic
- NG115 - Chronic obstructive pulmonary disease in over 16s: diagnosis and management
- CG163 - Idiopathic pulmonary fibrosis in adults: diagnosis and management
- NG106 - Chronic heart failure in adults: diagnosis and management
- (Olsson et al., 2023): Pulmonary hypertension associated with lung disease: new insights into pathomechanisms, diagnosis, and management.
- (Condliffe et al., 2023): Clinical-radiological-pathological correlation in pulmonary arterial hypertension.