Rebuttal From Dr Frantz

Abstract

The revised definition represents a well-intentioned effort to call attention to the prognostic significance of mild pulmonary hypertension across a host of disparate diseases and to detect pulmonary arterial hypertension earlier in the course of the disease. Earlier diagnosis of group I pulmonary arterial hypertension is a noble goal. However, the revised definition will do little to advance that goal because delayed diagnosis is much more a problem of failure to think of the diagnosis in symptomatic patients, than it is a problem with the definition. Accordingly, when the occasional patient is identified who happens to meet the revised definition only, that patient should be referred to an expert center, offered entry into registries, or, if available and feasible, pertinent clinical trials, not sought out or managed as part of usual clinical practice. Academic pulmonary hypertension centers should work to carefully phenotype such patients through vasodilator responsiveness, response to exercise using noninvasive or invasive cardiopulmonary exercise testing, stress echocardiography, observation of natural history, and consideration of relevant clinical trials. The broad recommendations of Dr Maron1Maron B.A. Point: Should the new definition of PH be the clinical practice standard? Yes.Chest. 2020; 157: 764-766Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar for healthy living (exercise programs, targeting obesity and metabolic syndrome, treating systemic hypertension, detecting occult hypoxemia and sleep-disordered breathing, promoting smoking cessation) are wise and applicable to the general population. Detection of mild pulmonary hypertension may occasionally help reinforce the importance of these recommendations, but should rarely be the deciding factor in their implementation if the health care system does what it should in promoting wellness in the general population. The potential for misclassification of patients meeting the revised hemodynamic definition, and by extension, errors in management posing risk of serious psychological and physical harm, are simply too great to justify incorporation of the revised definition into routine clinical practice. As with most new ideas in medicine, a period of careful clinical research to understand their true value and limitations is the more prudent approach. POINT: Should the New Definition of PH Be the Clinical Practice Standard? YesCHESTVol. 157Issue 4PreviewPulmonary hypertension (PH) is a heterogenous disease associated with increased morbidity or early mortality in the majority of affected patients.1 The accepted PH definition in use and essentially unchanged from 1973 to 2018 required a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg measured supine at rest by right heart catheterization (RHC). The importance of mPAP ≥ 25 mm Hg to clinical risk has over this time been affirmed across a wide range of PH subtypes.1,2 However, this definition was largely historical, and empiric data on mPAP that was normative or linked to clinical events were lacking. Full-Text PDF COUNTERPOINT: Should the New Definition of PH Be the Clinical Practice Standard? NoCHESTVol. 157Issue 4PreviewThe rationale for the revised definition rests upon three concepts: Full-Text PDF Rebuttal From Dr MaronCHESTVol. 157Issue 4PreviewDr Frantz1 raises several important, but nonetheless imprudent, reasons in favor of the counterpoint position against revising the hemodynamic definition of pulmonary hypertension (PH). Several of these arguments are addressed individually here. Full-Text PDF