PAH Flashcards
PH defined by:
mPAP > 20 at rest via rest heart catheterization
PVR > 2 wood units
Acute Vasodilator Testing
-Responder if mPAP decreases by 10, to value of < 40 without decrease in CO
-Indicates CCB
*Not performed in right HF or instability
CCB
-Must be responder to vasodilator testing
Agents: nifedipine, diltiazem, amlodipine
-Avoid verapamil
AE: edema, ging hyperplasia, HR
ERAs
-Bosentan, Ambrisentan, Macitentan
(TANS)
Warnings
-Teratogenic
-REMs (monitor pregnancy)
Bosentan
-Also monitor LFTs
Ambri
-Edema
Maciten
-Congestion, UTI
BL AE CUM
Require REMS
-ERAs
-Riociguat
PDE5i (Sildenafil, Tadalafil)
Warnings
-Hypotension
-PDE5is are CI with nitrates or guanylate cyclase
Sildenafil = 20 mg TID
-AE: HA, flush, dysp, nose bleed, visual impairment (FDB HIV)
Tadalafil = 20-40 QD
DDI: CYPs
Riociguat (sGC)
0.5-1 mg TID
-Increase by 0.5 every 2 weeks TID
-Target 2.5 mg TID
AE: dyspepsia, gastritis, hypotension
CI: nitrates, PDE5is
DDI: CYP
No smoking
Prostacyclins (Epoprostenol, Treprostinil, Iloprost, Selexipag)
Warnings
-Serious AEs
-Central line infections
-Risk of abrupt d/c
Epoprostenol
GOLD standard for high risk pts
2 ng/kg/min titrate to 25-45
AE: JIMI FRND
-HA, ND, rash, flushing
-Jaw pain, musco pain
-Infections
-Interrupt infusion = life threatening
Treprostinil
Similar AE to epo
-HA, NVD
-Infusion site pain or reaction
Oral
0.125 mg TID or 0.25 BID
(max 120 mg TID)
Inhaled Prostacyclins
Iloprost
6-9x per day
Treprostinil neb
3-9 breaths 4x per day
Treprostinil dry power
1 breath 4x per day
Selexipag
Avoid in severe hepatic failure
(moderate = 200 mcg starting)
With or without food, do not crush or chew
AE: HA, ND, MJ pain
DONT GIVE WITH CLOPIDOGREL
Guideline Algorithm
WITH cardiopulmonary comorbidities
-1. PDE5i or ERA
WITHOUT
-1. Low/Int risk = ERA + PDE5i
-2. High (20%+) = ERA + PDE5i + IV/SC PCA
-3. Add PRA or switch from PDE5i to RIO (If high risk, add IV/SC PCA or eval for lung transplant)
Supportive Tx
-Diet, less sodium
-Exercise
-Vaccinations
-Anticoag if not CI
-Oxygen
-Caution in high altitude
-Diuretics
Drugs that induce PAH
Dasatinib, pheny/pheno, methamphetamine