NATURAL MEDICINES & FAMILY PRACTICE
David Overton, PA-C 1315 Ruddell Rd. SE Lacey, WA 360-357-8054
Pulmonary Hypertension, Part 1
Most patient and practitioners have never heard about this treatable condition. At a recent medical conference, I was one only 8 out of 400 practitioners who knows about and treats increased pressure in the pulmonary arteries. If you look up pulmonary hypertension (PH) on the internet, it will sound like you will be dead within a couple of years. That’s because the American health system only recognizes severe PH. The World Health Organization has a better rating system (from early or mild to severe) that allows for early detection and treatment.
Normally the pulmonary pressure is about 1/8 of the systemic blood pressure. Severe PH is diagnosed by cardiac ultrasound with pulmonary pressure reach ¼ of systemic pressures. PH is most frequent caused by heart or lung conditions that cause blood vessel spasms and/or blood clots that increase pulmonary blood flow, pressure or both, including:
• Chronic lung disease where lung air sacks are destroyed, increasing pressure. Spirometry with pulmonary stress test in our office is recommended to diagnose and manage this. Chronic infections (diagnosed by symptoms or special tests), tobacco or marijuana exposure, asthma, genetic problems and environmental pollution are the major treatable causes of lung disease. See my articles on the web site.
• Heart disease due to congenital or other damage to the left heart valves or chambers increases left heart pressure which leads to PH. A variety of blood tests, ECG and cardiac ultrasound diagnoses the causes and leads to better management.
• Recurrent blood clots (micro clots or major clots) that damage lung vessels, leading to PH. Medicine is finding clotting disorders are very common and you may not have typical symptoms. D-dimer, fibrinogen, Factor V Leiden, von Willebrand’s factor tests should be done if clotting disorders are suspected. Aspirin response testing is recommended because 1 in 4 people do not respond to aspirin’s effects.
• Connective tissue diseases cause inflammation and scarring leading to PH. Tests for these disease and inflammation are available. Connective tissue diseases are highly associated with common viral and bacterial infections we can test for and manage.
• Sleep apnea and obesity, which we diagnose and manage, causes PH.
• Specific drugs:
Definite causes: appetite suppressants: fen-fen, others
Likely causes: amphetamines, L-tryptophan, methamphetamines
Possible causes: cocaine, phenylpropanolamine (sinus medicine), St. John’s Wort, chemotherapy, SSRI antidepressants (Prozac, Paxil, Zoloft & others)
• Viral infections, which are diagnosed and managed by history, exam and lab tests. See my articles.
• Liver congestion, which is diagnosed with liver tests.
• Rare parasitic infections and forms of anemia.
• Hyaline deposits, commonly present with high blood pressure, is a suspected treatable cause. See my articles on proteinaceous and amyloid deposits on the web site.
• Fibrin deposits, caused by genetic defects, clotting problems and infections, can be diagnosed and managed with specialized tests (the ISAC panel).
• Genetic defects that caused PH to run in families. Lifestyle changes and specific medicines can improve gene functions or outcomes.
PH is most common in women 20-40 years old and occasionally seen in children. Average age of diagnosis is 36. Obvious symptoms only become apparent when PH is severe, but a variety of early and treatable symptoms include:
• Vague breathing symptoms or shortness of breath
• Any type of chest pain. Women more likely have no chest pain or have pain in the upper chest, either breast, armpit or shoulder, upper back, neck, jaw or headaches.
• Palpitations, skipped, irregular or pounding heart beat
• Leg swelling or hand swelling
• 2/3 of women with circulation problems develop other symptoms, such as anxiety, sleep problems, digestive problems. Hot flashes are highly associated with heart disease.
Diagnosis and management of PH is mainly with cardiac ultrasound (echocardiogram) and should also include:
• Thorough history with a clinician experienced in treating PH
• Physical exam, which may reveal loud heart sounds, clicks, heart murmurs or abnormal heart sounds, other heart findings or edema (fluid retention)
• ECG may show right sided problems, strain or enlargement patterns.
• Chest X rays change with advanced PH and often miss an early diagnosis.
• Spirometry and blood tests to diagnose and manage the causes listed above.
There are two main methods to confirm the diagnosis:
• Heart catheterization, which is not commonly done. It must include left heart filing pressures and blood vessel reaction testing, which is not commonly done (in my experience)
• Treatments that improve symptoms and abnormal tests (as outlined above)
Conventional treatments are based on use of cardiac medicines with variable results and blocking clot formation, enhancing prostacylcin or endothelin (to relax blood vessel and slow blood vessel thickening) or boosting ATP or nitric oxide (which relaxes blood vessels and helps slow vessel thickening).
• Cardiac medications should be used at low doses and cautiously to prevent cardiovascular reactions and side effects should be monitored and treated.
• Specific PH drugs are available but are generally limited to severe PH because of cost, side effects, limited data, impracticality and/or some should not be used if left sided heart problems are present, coronary artery disease is present or with certain cardiac drugs.
• Drugs used for erections boost nitric oxide but are not commonly used because clinicians are wary of them, limited data and/or side effects or are limited to severe cases.
Lifestyle changes covered in appointments are always recommended because they help symptoms, treat heart disease, slow degenerative progression and may halt or reverse aspects of PH. In addition, we have found a number of drugs and/or supplements that are effective in manage the causes and symptoms of PH.
References: 1. Pathological Basis of Disease, 8th Edition,2010, Kumar et. al. 2. Advances in Current Treatments of PAH in Primary Care, H. Farber MD & R. Codario MD, Seattle, WA October 2009.
NATURAL MEDICINES & FAMILY PRACTICE
David Overton, PA-C 1315 Ruddell Rd. SE Lacey, WA 360-357-8054
Pulmonary Hypertension, Part 2
So what causes pulmonary hypertension (PH)? Most of the causes are so complex many medical practitioners do not understand or treat PH. Consequently, many patients struggle to understand or find adequate treatments. See Part 1 for a more complete list of treatable causes. PH is most frequently caused by heart and lung conditions that increase pulmonary blood flow or pressure (or both), stiffness in the lungs or left heart. These are most commonly due to:
• Chronic lung disease or infections and other conditions that damage the lungs. This causes low oxygen (hypoxia) as well as lung damage that increases pulmonary pressure.
• Heart damage due to various conditions over your lifespan or genetic damage. There is a long list of treatable conditions that can damage the heart. For example, mitral or aortic valve problems (commonly due to immune, infectious, collagen, hyaline or genetic problems as well as insulin resistance, high blood pressure, arteriosclerosis or obesity) leads to an increase in pulmonary vein pressure which leads to pulmonary artery pressure problems. These are best diagnosed and managed with heart and artery tests, blood and urine tests.
• Micro-clots and clots. Scarring in the vessels lead to increased pressure. Best managed with coagulation tests. Immune problems and infections commonly cause micro-clots.
• Connective tissue diseases lead to inflammation and scarring in the pulmonary vessels. Commonly due to genetic, infectious, amyloid, hyaline or other testable and treatable problems.
• Sleep apnea commonly associated with obesity contributes to PH. See me for weight loss.
Much has been learned by studying the molecular basis of the uncommon familial genetic form of PH. PH is associated with damage to the small and large vessels caused by scarring or micro clots. The uncommon genetic form is due to genes which bind cytokines (immune complexes), such as CRP, TGF-b (tumor growth factor), BMP (bone morphogenetic protein), activin and inhibin. Please note infections and excess belly fat also cause cytokine binding. We might want to test cytokines.
The common forms of PH are due to cytokine (immune) problems, but also pressure changes in the pulmonary arteries and injury due to fibrin. I always recommend we do immune labs and test for fibrin, which is quite challenging. Standard blood tests do not measure fibrin or cytokines and we may need specialty labs. These problems lead to decreased prostacylcin, ATP, nitrous oxide and release of endothelin, which causes platelets to clump (micro clots). Growth factors and additional cytokines (tumor necrosis factor, interleukins, natural killer cells), cause further damage. Some of these things we can test and all can be treated.
Some people have blood vessel spasms that contribute to PH. Some foods and drugs cause PH. Fen-fen, phenteramine, any weight loss drug and serotonin drugs are thought to contribute to PH. Food allergy and sensitivity testing should be considered or done.
All forms of PH have artery damage and many people have right sided heart enlargement. At autopsy, micro clots are commonly found leading to scarring and damage. PH ranges from mild damage in the small vessels with minimal symptoms to progressive severe damage in large and small vessels with significant symptoms in advanced cases.
Conventional drugs include oxygen, calcium blockers, nitroglycerin, anti coagulants, digoxin and diuretics which are helpful in the short course. Prostacyclin analagues, blood vessel cell blockers and phosphodiesterase-5 blockers are available, but costly and have side effects. Most of my patients are responding to alternative medicines that work on these same problems without the side effects.
Gene therapy has been successful in animals and may be possible for humans in the future. Stem cell therapy holds promise in the future. We have 8 or 9 supplements now that support or improve gene functions and stem cells and they seem to be helping patients (note: the FDA has not approved these statements).
If you have pulmonary hypertension, we can work together to manage these to slow or halt progressive problems.
References: Pathological Basis of Disease, 8th Edition, 2010, Kumar et. al