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Physician Training in Pulmonary Hypertension


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Veronica Franco, MD
Ohio State University
Columbus, OH, USA
Veronica.franco@osumc.edu



Pulmonary hypertension affects approximately 25 million individuals worldwide and causes premature disability and death from right ventricular (RV) failure. Specific pulmonary vasodilator medications are only indicated in patients with pulmonary arterial hypertension (PAH). Long-term mortality remains high despite considerable advances in medical therapy for PAH, largely as a result of right heart failure. There remains an unacceptable long delay from the onset of clinical symptoms to diagnosis, of approximately 2-3 years. Patients usually present when the pathologic changes are advanced and sometimes irreversible; many patients have already developed RV failure or are functional class III or IV. Diagnosis at this stage is associated with worse prognosis, emphasizing the importance of early disease diagnosis and aggressive treatment. Other, more common types of pulmonary hypertension, like pulmonary venous hypertension (from left-sided heart disease) or that one associated with hypoxia (from lung disease), do not benefit from specific pulmonary vasodilators and the treatment is focus on treating the underlying primary disease.

The management of pulmonary hypertension has advanced dramatically during the past 25 years but physician training lags behind. Expertise in the diagnosis and treatment of pulmonary hypertension remains scarce. Diagnosis and management of this disease requires a multidisciplinary approach and liberal referral to physicians experienced in evaluating and treating PAH, particularly to determine if patients will benefit from specific PAH vasodilator therapy. Delayed diagnosis and treatment of PAH are net effects of the gap between advancing knowledge and limited educational opportunity [1].

The American College of Graduate Medical Edition requires formal instruction, clinical experience, and demonstrated competence in evaluation and management of pulmonary hypertension [2,3]. Task force recommendations for competency in pulmonary medicine and cardiology include expectations for expertise in the assessment and management of pulmonary hypertension. However, the majority of pulmonary training programs in the United States offer little or no formal training in echocardiography, limited training in right-sided heart catheterization to evaluate pulmonary hypertension, and limited exposure to patients with PAH treated with advanced therapies, such as parental prostacyclins [1]. Cardiology fellowships routinely offer training in right-sided heart catheterization and echocardiography, but exposure to patients with the full spectrum of disease (eg, CTEPH, PAH, and life-saving therapies such as prostacyclins or pulmonary endarterectomy) are limited. Further, cardiology trainees perform right heart catheterizations during their "cath lab rotation" which is supervised mostly by interventional cardiologists. The majority of general cardiology fellows have limited exposure to advanced heart failure, pulmonary hypertension or congenital heart disease specialists, who performed their procedures with subspecialty fellows.

Individual cardiology or pulmonary trainees in the United States may use their elective rotations to gain additional training and experience related to pulmonary hypertension, but this additional training is left to the fellows' preferences and long term goals. Currently, there are a few opportunities for additional physician education and training directly related to pulmonary hypertension. The Pulmonary Hypertension Association funds fellowship awards for the development of investigators in this field. Specialized pulmonary vascular disease education is usually provided to cardiology fellows doing an additional year of training in the subspecialties of advanced heart failure and transplantation as well as adult congenital heart disease in some academic centers, but not all.

In order to improve outcomes in pulmonary hypertension, particularly in PAH, an earlier diagnosis is required to prevent irreversible RV changes and failure. Physician education is essential, particularly during cardiology and pulmonary fellowships as they are the 1st line specialists to evaluate patients with dyspnea and fatigue. We must teach trainees in both specialties- 1) the appropriate techniques during cardiac catheterization, particularly the importance of an accurate wedge pressure; 2) initial evaluation protocols / diagnostic tests needed; and 3) basic knowledge about side effects and mechanism of action in specialized PAH vasodilators, as not every patient will be able to be evaluated frequently at specialized centers and some request co-management.

The burden of pulmonary hypertension is likely to grow in the United States as patients age and develop chronic respiratory disorders and left ventricular diastolic dysfunction. The ever-present question of what patients will benefit or not of specific PAH vasodilators will be commonly discussed between cardiologists and pulmonologists. Appropriate fellowship education, with a minimum time of specialized training in pulmonary hypertension should be required for trainees, to achieve earlier pulmonary hypertension diagnosis and better evaluation and treatment of these patients. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Elliott CG, Barst RJ, Seeger W, et al. Worldwide physician education and training in pulmonary hypertension. Pulmonary vascular disease: the global perspective. Chest 2010; 137: S85-S94.
  2. O'Gara PT, Adams JE, Drazner MH, et al. COCATS 4 task force 13: training in critical care cardiology. J Am Coll Cardiol 2015; 65: 1877-1886.
  3. Buckley JD, Addrizzo-Harris DJ, Clay AS , et al . Multisociety task force recommendations of competencies in Pulmonary and Critical Care Medicine. Am J Respir Crit Care Med. 2009; 180: 290 - 295.



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