Post-capillary pulmonary hypertension – hemodynamic profile

Post-capillary pulmonary hypertension arises from raised pressure in the left heart transmitted backward into the pulmonary circulation. Under ESC/ERS 2022 it is present when the mean pulmonary artery pressure exceeds 20 mmHg together with a pulmonary artery wedge pressure above 15 mmHg. Pulmonary vascular resistance subdivides this group further: at most 2 Wood units defines isolated post-capillary pulmonary hypertension, above 2 Wood units defines the combined pre- and post-capillary form. The distinction matters clinically because the combined form indicates disease of the pulmonary vasculature in its own right, additional to the left heart disease.

For educational use only. Not for clinical use.

Hemodynamic profile

ParameterDirectionTypicalNormal range
mPAP↑> 20 mmHg< 20
PCWP↑> 15 mmHg6-15
PVR→≤ 2 WU isolated, > 2 WU combined< 160 (< 2 WU)
ZVD→normal to elevated2-6
CI→normal to reduced2.5-4.0

Differentiation

Differentiate fromDiscriminating parameterExplanation
Pre-capillary pulmonary hypertensionPCWPPCWP separates the two forms: above 15 mmHg is post-capillary, up to 15 mmHg pre-capillary. A raised PCWP points to the left heart as the cause.
Cardiogenic shockCIBoth show a raised PCWP. In cardiogenic shock, however, the cardiac index has fallen below 2.2 L/min/m² and there is manifest organ hypoperfusion.

Causes

  • Heart failure with reduced ejection fraction
  • Heart failure with preserved ejection fraction
  • Mitral valve disease, both stenosis and regurgitation
  • Aortic valve disease
  • Restrictive cardiomyopathy
  • Constrictive pericarditis

Clinical context

The symptom picture is shaped by the underlying left heart disease: exertional dyspnoea, orthopnoea and signs of pulmonary congestion. Hemodynamically the raised PCWP is the starting point, with mean pulmonary artery pressure following passively. Pulmonary vascular resistance is decisive for classification: if it stays at or below 2 Wood units the form is isolated post-capillary, with the pressure rise explained entirely by backward transmission. Above 2 Wood units the form is combined pre- and post-capillary, with an additional intrinsic pulmonary vascular disease and a less favourable prognosis. The transpulmonary gradient alone is no longer used for this classification.

Frequently asked questions

How is post-capillary pulmonary hypertension defined?
Per ESC/ERS 2022 by a mean pulmonary artery pressure above 20 mmHg together with a PCWP above 15 mmHg. By definition the cause therefore lies in the left heart.
What separates the isolated from the combined form?
Pulmonary vascular resistance. Up to 2 Wood units the form is isolated post-capillary; above that it is combined pre- and post-capillary with additional pulmonary vascular disease.
Why does the combined form matter prognostically?
A raised pulmonary vascular resistance indicates remodelling of the pulmonary vasculature in addition to the left heart disease. That remodelling does not readily reverse with treatment of the left heart alone.
Is PCWP alone enough for classification?
For separating pre- from post-capillary, yes; for the subsequent subdivision, no. Only pulmonary vascular resistance determines whether an additional pre-capillary component is present within the post-capillary group.
Load example values in the calculatorTo the Swan-Ganz calculator