Clinical profile of patients with pulmonary hypertension

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Keywords

pulmonary hypertension, left heart disease, clinical profile

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Correspondence

Chayan Kumar Singha
Email: ck.singha@bsmmu.edu.bd 

Publication history

Received: 7 Mar 2025
Accepted: 25 June 2025
Published online: 8 July 2025

Handling editor

Reviewer

Funding

Funded by Bangabandhu Sheikh Mujib Medical University, Grant (Memo No: BSMMU/2023/13314(26), dated 30 October 2023)

Ethical approval

Approved by IRB of University Cardiac Center, Bangladesh Medical University (BSMMU/2023/6937, dated 9 May 2023)

Trial registration number

Not applicable

Copyright

© The Author(s) 2025; all rights reserved. 
Published by Bangabandhu Sheikh Mujib Medical University (currently Bangladesh Medical University).
Key messages
Pulmonary hypertension remains under-recognized in Bangladesh. Dyspnea, chest pain and fatique were the most common manifestations in this series; 16.7% were severe cases. These are different from other populations worldwide. Therefore, pulmonary hypertension in Bangladesh deserves special attention.
Once considered an orphan disease, pulmonary hypertension is now recognized as a major contributor to morbidity and mortality, yet it continues to receive limited attention in clinical practice worldwide [1]. Currently, pulmonary hypertension affects over 70 million people worldwide, with a 10% incidence among those over 65 in both developed and developing countries. Pulmonary hypertension was defined as a mean pulmonary arterial pressure of more than 20 mmHg at rest by the sixth world symposium on pulmonary hypertension in 2018 [2]; however, the guidelines of the European Respiratory Society and European Society of Cardiology consider a threshold of 25 mmHg at rest [3]. 
 
In Bangladesh, pulmonary hypertension patients experience delayed or missed diagnosis due to non-specific symptoms, which sometimes lead to early preventable death. This study investigates the clinical characteristics of pulmonary hypertension in Bangladeshi adults, offering valuable insights for enhancing management approaches.
 
The study was conducted in the Department of Cardiology, Bangladesh Medical University, and included 60 patients (29 men and 31 women) with previously diagnosed pulmonary hypertension, confirmed by echocardiography, from November 2023 to April 2024.  A 12-lead resting electrocardiogram (10 mm/mV, 25 mm/s) and echocardiography using a Simens GE Vivid E9 machine were performed. Transesophageal echocardiography was done when needed. Right ventricular systolic pressure and mean    pulmonary artery pressure were measured according to the 2022 the European Society of Cardiology pulmonary hypertension guidelines. Right heart catheterization was performed in three idiopathic pulmonary hypertension cases with elevated RVSP, preserved left ventricular function, and no significant valvular disease on echocardiography. As per the 2022 guidelines of the European Society of Cardiology and European Respiratory Society, right heart catheterization was necessary for definitive hemodynamic confirmation. Pulmonary hypertension is categorized into five groups based on etiology, while its severity is evaluated using right ventricular systolic  [4].
 
The mean age of the participants was 49.6 (14.6) years, with 31 females (52%) and 29 males (48%). Type 2 pulmonary hypertension was the most frequent type (45.0%) with a mean pulmonary artery pressure of 46.0 (7.6) mmHg, followed by Type 1 pulmonary hypertension (31.6%). Pulmonary hypertension was mild in 46.7%, moderate in 36.7%, and severe in only 16.7%. Common symptoms were dyspnea (93.3%), chest pain (91.6%), and fatigue (93.3%). Right heart catheterization in three idiopathic pulmonary hypertension cases showed a mean pulmonary artery pressure of 56.7 (10.7) mmHg, a mean pulmonary vascular resistance of 9.3 (0.8) Wood units, and a mean pulmonary capillary wedge pressure of 10.9 (1.0) mmHg.
 
In our study, most patients were comparatively younger to middle-aged. Krishna and Venu reported a higher mean age of 51.9 (11.5) years [5]. The younger age distribution in our cohort may reflect demographic differences and progressiveness of the disease. 

Categories

Number (%)

Sex

 

   Male

36 (60.0)

   Female

24 (40.0)

Age in yearsa

8.8 (4.2)

   Education

 

   Pre-school

20 (33.3)

   Elementary school

24 (40.0)

   Junior high school

16 (26.7)

Cancer diagnoses

 

   Acute lymphoblastic leukemia

33 (55)

   Retinoblastoma

5 (8.3)

   Acute myeloid leukemia

4 (6.7)

   Non-Hodgkins lymphoma

4 (6.7)

   Osteosarcoma

3 (5)

   Hepatoblastoma

2 (3.3)

   Lymphoma

2 (3.3)

   Neuroblastoma

2 (3.3)

   Medulloblastoma

1 (1.7)

   Neurofibroma

1 (1.7)

   Ovarian tumour

1 (1.7)

   Pancreatic cancer

1 (1.7)

   Rhabdomyosarcoma

1 (1.7)

aMean (standard deviation)

Categories

Number (%)

Sex

 

   Male

36 (60.0)

   Female

24 (40.0)

Age in yearsa

8.8 (4.2)

Education

 

   Pre-school

20 (33.3)

   Elementary school

24 (40.0)

   Junior high school

16 (26.7)

Cancer diagnoses

 

Acute lymphoblastic leukemia

33 (55)

Retinoblastoma

5 (8.3)

Acute myeloid leukemia

4 (6.7)

Non-Hodgkins lymphoma

4 (6.7)

Osteosarcoma

3 (5)

Hepatoblastoma

2 (3.3)

Lymphoma

2 (3.3)

Neuroblastoma

2 (3.3)

Medulloblastoma

1 (1.7)

Neurofibroma

1 (1.7)

Ovarian tumour

1 (1.7)

Pancreatic cancer

1 (1.7)

Rhabdomyosarcoma

1 (1.7)

aMean (standard deviation)

Table 1 Severity, types and clinical features of patients with pulmonary hypertension (n=60)

Variables

Results

Number (%)

Sex

Male

29 (48.0)

Female

31 (52.0)

Symptoms 

 

Dyspnea

56 (93.3)

Chest pain

55 (91.7)

Fatigue

55 (91.7)

Leg oedema

47 (78.3)

Palpitation

49 (81.6)

Cough

27 (45.0)

Hoarseness of voice

3 (5.0)

Hemoptysis

5 (8.3)

Syncope

3 (5.0)

Cyanosis

3 (5.0)

Severity of pulmonary hypertension  

Mild

28 (46.7)

Moderate

22 (36.7)

Severe

10 (16.7)

Types of pulmonary hypertension

Type 1

19 (31.6)

Type 2

27 (45.0)

Type 3

7 (11.7)

Type 4

3 (5.0)

Type 5

4 (6.7)

Mean (SD)

Age (years)

49.6 (14.6)

RVSP (mmHg) by severity of pulmonary hypertension    

Mild

43 (7.0)

Moderate

58 (5.0)

Severe

80 (7:0)

mPAP (mmHg) of type of pulmonary hypertension   

Type 1

54 (28.9)

Type 2

46 (7.6)

Type 3

47.4 (11.0)

Type 4

53 (2.0)

Type 5

49.5 (16.2)

SD indicates standard deviation; RVSP, right ventricular systolic pressure; mPAP, mean pulmonary artery pressure. RVSP 36–49 mmHg is mild, 50 –69 mmHg is moderate, and ≥70 mmHg is severe pulmonary hypertension. Types of pulmonary hypertension are based on etiology as per reference.

Category

Key Factors

Weight

Strengths

Strong management support, skilled workforce, compliance with legal regulations

0.338

Weaknesses

Logistical complexity, inadequate segregation, financial constraints

0.13

Opportunities

Industry collaboration, environmental policies, new technology

0.094

Threats

Limited space, lack of coordination, high investment risk

0.329

Pain level

Number (%)

P

Pre

Post 1

Post 2

Mean (SD)a pain score

4.7 (1.9)

2.7 (1.6)

0.8 (1.1)

<0.001

Pain categories

    

   No pain (0)

-

1 (1.7)

31 (51.7)

<0.001

   Mild pain (1-3)

15 (25.0)

43 (70.0)

27 (45.0)

 

   Moderete pain (4-6)

37 (61.7)

15 (25.0)

2 (3.3)

 

   Severe pain (7-10)

8 (13.3)

2 (3.3)

-

 

aPain scores according to the visual analogue scale ranging from 0 to 10; SD indicates standard deviation

Regarding gender distribution, female patients were predominantly more. For instance, females comprised 59% of cases in the Swiss registry [6] and 65.3% of cases in the French registry [7]. In contrast, Bansal et al. [8] found somewhat more males (54%) than females (46%).  In Bangladesh, women often have limited healthcare access, and our study found a greater number of female participants. This also reflects the known female predominance in pulmonary hypertension.
 
Similar to Dzudie et al., pulmonary hypertension due to left heart disease (Type 2) was the most common type found in our study [9]. Type 1 pulmonary hypertension was our second most prevalent type and exhibited the highest mPAP on echocardiography. This is likely due to progressive vascular remodeling, increased pulmonary vascular resistance, and absence of left-sided pressure overload. The predominance of type 2 pulmonary hypertension indicates that it arises from the chronicity of left heart disease. This condition is amenable to prevention and treatment. 
 
Most participants presented with mild to moderately severe pulmonary hypertension based on RVSP measurements. Krishna and Venu found a similar distribution, with 32% having mild, 38% having moderate, and 30% experiencing severe pulmonary hypertension [5]. This distribution suggests that many patients had mild to moderate disease, which may reflect disease progression or clinical presentation differences. 
The most frequently reported symptoms were shortness of breath, fatigue, and chest pain. Bansal et al. reported dyspnea (86.4%) and cough (77.5%) as the most common symptoms [8].  These findings are commonly seen in pulmonary hypertension, and symptoms become more pronounced with the progression of the disease.
 
Right heart catheterization in three idiopathic pulmonary hypertension cases confirmed pre-capillary pulmonary hypertension with significantly elevated pulmonary vascular resistance and preserved wedge pressures, suggesting that it was pre-capillary. AL-Kinani observed similar mean pulmonary artery pressure values [10].
 
This study highlights the clinical profile and hemodynamic characteristics of pulmonary hypertension in Bangladeshi adults, with left heart disease (Type 2) emerging as the most common type. The majority of cases were mild in severity. Fatigue and dyspnea were the predominant presenting symptoms.
Acknowledgements
None
Author contributions
Conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: CKS, MFI, DM, JA, EB. Drafting the work or reviewing it critically for important intellectual content: CKS, MFI, DM, JA, EB. Final approval of the version to be published: CKS, MFI, DM, JA, EB. Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: CKS, MFI, DM, JA, EB. 
Conflict of interest
We do not have any conflict of interest.
Data availability statement
We confirm that the data supporting the findings of the study will be shared upon reasonable request.
Supplementary file
None
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