Target Audience:

Who should attend:

• Clinical faculty from the University of Pittsburgh School of Pharmacy
• Clinical staff pharmacists employed by the University of Pittsburgh Medical Center and deployed throughout the hospital campus in unit based roles and centrally in the department of pharmacy's main pharmacy
• Student pharmacy interns currently working within the department of pharmacy
• Certified Pharmacy Technicians

Abstract
There are 5.7 million patients with heart failure in the United States and 50-70% of these patients are affected by pulmonary hypertension. Pulmonary hypertension secondary to left heart disease (PH-LHD) or World Health Organization (WHO) Group 2 is a marker of chronicity in heart failure patients and is associated with poor prognosis/decreased survival. Although PH-LHD has the highest prevalence out of all classifications of pulmonary hypertension, treatment with vasodilators such as prostacyclin analogues, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and soluble guanylate cyclase agonists are only recommended for pulmonary arterial hypertension (PAH) or WHO Group 1 due to the potential to cause harm in PH-LHD.

There are two phenotypes of PH-LHD which include isolated post capillary pulmonary hypertension (Ipc-PH) and combined pre-post capillary pulmonary hypertension (Cpc-PH). These phenotypes differ hemodynamically and therefore may vary in their response to treatment options available. Many clinical trials examining vasodilator therapies in PH-LHD have heterogenous inclusion criteria when examining hemodynamic parameters on right heart catheterizations, creating a lack of strong evidence for utilizing traditional PAH pharmacotherapy in patients with PH-LHD. This presentation outlines the prevalence, etiology, and pathophysiology of PH-LHD as well as the evidence to support utilizing traditional PAH therapies in specific patient populations with PH-LHD.

Educational Objectives:

Upon successful completion of this continuing pharmacy education program, the participant should be able to:

• Describe the incidence and pathophysiology of pulmonary hypertension.
• Recognize barriers to selecting appropriate treatment for pulmonary hypertension secondary to left heart disease.
• Discuss the evidence surrounding vasodilator therapies and future directions of research in pulmonary hypertension secondary to left heart disease.

Pharmacy Continuing Education Credits In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.. The assigned universal program number(s) is JA4008223-0000-23-071-H01-P.  This knowledge-based activity provides 1  contact hours of continuing pharmacy education credit.

Suggested Additional Reading:

1. Assad TR, Maron BA, Robbins IM, et al. Prognostic Effect and Longitudinal Hemodynamic Assessment of Borderline Pulmonary Hypertension. JAMA Cardiol. 2017;2(12):1361-1368. doi:10.1001/jamacardio.2017.3882
2. Assad TR, Hemnes AR, Larkin EK, et al. Clinical and Biological Insights Into Combined Post- and Pre-Capillary Pulmonary Hypertension. J Am Coll Cardiol. 2016;68(23):2525-2536. doi:10.1016/j.jacc.2016.09.942
3. Barst RJ. Pulmonary hypertension: past, present and future. Ann Thorac Med. 2008;3(1):1-4. doi:10.4103/1817-1737.37832
4. Bonderman D, Ghio S, Felix SB, et al. Riociguat for patients with pulmonary hypertension caused by systolic left ventricular dysfunction: a phase IIb double-blind, randomized, placebo-controlled, dose-ranging hemodynamic study. Circulation 2013;128:502–11.
5. Bursi F, McNallan SM, Redfield MM, et al. Pulmonary pressures and death in heart failure: a community study. J Am Coll Cardiol. 2012;59(3):222-231. doi:10.1016/j.jacc.2011.06.076
6. Califf RM, Adams KF, McKenna WJ, et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure: The Flolan International Randomized Survival Trial (FIRST). Am Heart J. 1997;134(1):44-54. doi:10.1016/s0002-8703(97)70105-4
7. Galiè N, McLaughlin VV, Rubin LJ, Simonneau G. An overview of the 6th World Symposium on Pulmonary Hypertension. Eur Respir J. 2019;53(1):1802148. Published 2019 Jan 24. doi:10.1183/13993003.02148-2018
8. Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119. doi:10.1093/eurheartj/ehv317
9. Gall H, Felix JF, Schneck FK, et al. The Giessen Pulmonary Hypertension Registry: Survival in pulmonary hypertension subgroups. J Heart Lung Transplant. 2017;36(9):957-967. doi:10.1016/j.healun.2017.02.016
10. Guazzi M, Vicenzi M, Arena R, et al. Pulmonary hypertension in heart failure with preserved ejection fraction: a target of phosphodiesterase-5 inhibition in a 1-year study. Circulation 2011;124:164–74.
11. Hefke T, Zittermann A, Fuchs U, Schulte-Eistrup S, Gummert JF, Schulz U. Bosentan effects on hemodynamics and clinical outcome in heart failure patients with pulmonary hypertension awaiting cardiac transplantation. Thorac Cardiovasc Surg. 2012;60(1):26-34. doi:10.1055/s-0030-1250726
12. Koller B, Steringer-Mascherbauer R, Ebner CH, et al. Pilot study of endothelin receptor blockage in heart failure with diastolic dysfunction and pulmonary hypertension (BADDHY-trial). Heart Lung Circ 2017;26:433–41.