METHAMPHETAMINE-ASSOCIATED PULMONARY HYPERTENSION PRESENTING WITH INTERMITTENT DYSPNEA

Abstract

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Methamphetamine-associated PAH (Meth-APAH) is a rare subtype of PAH associated with exposure to the highly addictive stimulant drug, methamphetamine. Although Meth-APAH was initially described nearly two decades ago, it is often diagnosed only later in the disease's course. CASE PRESENTATION: A 59 year-old-woman with a history of hypertension, tobacco use (3-4 cigarettes/day) who was sent to the hospital by outpatient cardiology to evaluate for severe pulmonary hypertension seen on transthoracic echocardiogram (TTE). The patient's PCP had referred her to outpatient cardiology to evaluate intermittent dyspnea on exertion. On exam, the patient reported she had been asymptomatic for several weeks. Her physical examination was unremarkable except for poor dentition. Upon additional questioning, the patient revealed that she had been smoking methamphetamine for the past 15 years; a subsequent urine drug screen was positive for amphetamine. TTE showed a moderately dilated right ventricle (RV), moderately reduced RV systolic function, and an estimated pulmonary artery systolic pressure of 105 mmHg. Right heart catheterization demonstrated a pulmonary artery pressure of 80/30 mmHg, a mean pressure of 45 mmHg, a normal right atrial pressure and a normal wedge pressure. Vasoreactivity testing was not done. CTA heart was negative for significant coronary disease. Ventilation perfusion scan was negative. Autoimmune workup was negative. The patient was diagnosed with Meth-APAH and was referred to a PAH specialty care center for further evaluation and treatment. DISCUSSION: This case illustrates the importance of a timely diagnosis of Meth-APAH and emphasizes the need for vigilant screening of patients who use Meth for the early signs and symptoms of PAH. If TTE had not been considered for our patient, the opportunity to slow disease progression would have likely been lost. The potential consequences would have been severe because Meth-APAH is associated with more RV dysfunction and over twice the risk of clinical worsening or death when compared to idiopathic PAH. Current guidelines recommend monitoring asymptomatic patients who use Meth for the development of symptoms of PAH. However, the diagnosis of PAH is often made only in the advanced stages when right heart failure is apparent because the early symptoms of PAH are nonspecific. CONCLUSIONS: Clinicians should ensure a drug history is obtained as part of the workup of pulmonary hypertension regardless of the level of dyspnea or hypoxemia Consider Meth-PAH in patients with a history of methamphetamine use presenting with nonspecific complaints such as dyspnea on exertion, fatigue, or syncope.The diagnosis of Meth-PAH should not be missed as opportunities for counseling and treatment opportunities that may prevent progression of the severity of PAH. There are now numerous therapeutic options for PAH. REFERENCE #1: Zamanian RT, Hedlin H, Greuenwald P, et al. Features and Outcomes of Methamphetamine-associated Pulmonary Arterial Hypertension. Am J Respir Crit Care Med. Mar 15 2018;197(6):788-800. doi:10.1164/rccm.201705-0943OC REFERENCE #2: Klinger JR, Elliott CG, Levine DJ, et al. Therapy for Pulmonary Arterial Hypertension in Adults: Update of the CHEST Guideline and Expert Panel Report. Chest. Mar 2019;155(3):565-586. doi:10.1016/j.chest.2018.11.030 REFERENCE #3: Brown LM, Chen H, Halpern S, et al. Delay in recognition of pulmonary arterial hypertension: factors identified from the REVEAL Registry. Chest. Jul 2011;140(1):19-26. doi:10.1378/chest.10-1166 DISCLOSURES: No relevant relationships by Daniel Antwi-Amoabeng, source=Web Response No relevant relationships by Robert Luong, source=Web Response No relevant relationships by Farah Madhani-Lovely, source=Web Response