The interest of the Indian pulmonologists on PH (pulmonary hypertension) has been created and rejuvenated after the availability of anti PH drugs. They are now getting concerned about the presence of class III PH in their day to day practice.

Unfortunately, the country does not have any database on the prevalence of PH or PAH (pulmonary arterial hypertension). Limited and recent publications suggest that the class III PH is an entity of concern and the only available etiological distribution of PH is credited by Institute of Pulmocare & Research. ⁽¹⁾

There are several issues that actually hinder understanding the dimension of PH in the country. Firstly, all the guidelines preach the PH diagnosis to be based on RHC (right heart catheterization) ^{(2, 3)}. Although radiological signs exist with cent percent specifically^(4,5,6,7), they are not given much importance. Doppler echocardiography is not precise enough, ⁽⁸⁾ though a value of pulmonary arterial pressure ≥50 mm of Hg been measured by echocardiography cannot be ignored. Finally, the treatment of class III PH in different conditions is also not clearly delineated by the international guidelines.

Naturally, the lacunae offer freedom for individual physicians to diagnose and treat PH but it demands good justification for treatment without RHC. It is agreeable ethically to treat a patient with respiratory symptoms (when implied to PH) despite optimum treatment of the underlying disease. The authors in the article 'Sildenafil in treating Pulmonary Hypertension: the initial experience in a tertiary out-patient department practice' have chosen to impress us with the bold decision of offering anti PH therapy to such population of class III PH in our country. Agreeably again, RHC may not be essential for monitoring patients on anti PH therapy. The follow up of the patients however, could be made more objective with inclusion of 6 minute walk test.

In a scenario of no database and an unlikely prospect of quick inclusion of RHC in diagnostic practice for PH, the article ignites questions to initiate a debate for consideration of a non-invasive diagnosis of PH as an indication for treatment especially in patients with advanced WHO functional status and refractoriness of symptoms despite the best possible the treatment of an the underlying pulmonary pathologies.

Beyond that, supporting the decision with measurement of quality of life change is welcome though CAT (COPD assessment test) is not validated for PH and not been use for many conditions beyond COPD (chronic obstructive pulmonary disease), ⁽⁹⁾ and ILD (interstitial lung disease). ⁽¹⁰⁾ Despite appreciating logistic problem as admitted by the authors, other objective parameters could have been better to support the outcome. The article reflects a desperate effort to overcome the existing deficiencies at the ground realities to match the 'evidence based' standards of the guidelines in the best possible scientific and humane way. The pivotal question that lingers for response from the scientific community is "can we deprive suffering patients with the excuse of lack of quality evidence?"

REFERENCE

1. Saha D, Bhattacherjee P D, Das S K, Dey R, Ghosh M, Dutta I, Sarma M, Ghosh A, Bhattacharyya P S. Group III Pulmonary Hypertension: relative frequency of different etiologies in a referral pulmonary OPD. Pulmo Face, Vol. XIII No. 1, Sep.-2013 (non indexed journal ISSN no. 2347 – 4823).

2. Galie N, Hoeper M M, Humbert M, Torbicki A, Vachiery J L, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the 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 the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30: 2493–2537.

3. Mc Laughlin V V, Park M H, Rosenson R S, Rubin L J, Tapson V F, Vagre J. ACCP/AHA: 2009 Expert Consensus Document on Pulmonary Hypertension. Jr A. Col Cardiol 2009; 35:14, 1573- 1619.

4. Kanemoto N, Furuya H, Etoh T, Sasamoto H, and Matsuyama S. Chest roentgenograms in primary pulmonary hypertension. Chest, 1979: 76, 45 – 49

5. Bush A, Gray H, Denison D M. Diagnosis of pulmonary hypertension from radiographic estimates of pulmonary arterial size. Thorax 1988; 43:127-131.

6. Tan RT, Kuzo R, Goodman LR, Siegel R, Hassler GB, Presberg KW. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Medical College of Wisconsin Lung Transplant Group. Chest 1998; 113(5): 1250–1256.

7. Ng CS, Wells AU, Padley SP. A CT sign of chronic pulmonary arterial hypertension: the ratio of main pulmonary artery to aortic diameter. J Thorac Imaging 1999; 14(4):270–278.

8. Bhattacharyya PS. Can we treat class III Pulmonary Hypertension without Right Heart Catheterization? (Manuscript ID: "pvri_2_13". Send it to PVRI Journal as an editorial).

9. Jones PW, Harding G, Berry P et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009;34:648-654.

10. Tachikawa R, Otsuka K, Takeshita J, Tanaka K, Matsumoto T, Monden K. Evaluation of the chronic obstructive pulmonary disease assessment test for measurement of health-related quality of life in patients with interstitial lung disease. Respirology. 2012 Apr; 17(3):506-12. doi: 10.1111/j.1440-1843.2012.02131.x.

Dr. Dhiman Ganguly,
Institute of Pulmocare and Research
CB-16, Sector-1, Salt Lake,
Kolkata, West Bengal, India
E-mail: parthachest@yaahoo.com