Diagnosis and management of combined post- and precapillary pulmonary hypertension in a patient with multiple comorbidities.

Diagnosis of pulmonary hypertension requires a laborious investigation that must be performed in accordance with international guidelines. Right-heart catheterization is the gold standard examination to assess the degree of hemodynamic impairment of post- or precapillary origin, guiding management. The presence of comorbidities is becoming rather frequent in real-life pulmonary hypertension cases, thus creating diagnostic and therapeutic complexity. We present a case of combined post- and precapillary pulmonary hypertension in a patient with ischemic heart disease and combined pulmonary fibrosis and emphysema, in order to describe the diagnostic algorithm for pulmonary hypertension and elucidate the problematic aspects of managing this debilitating disease in a patient with several comorbidities. Current guidelines do not support the use of specific vasodilator treatment in group II - due to heart disease and group III-due to lung disease pulmonary hypertension, unless the patient presents with severe pulmonary hypertension (mean pulmonary artery pressure > 35 mm Hg or cardiac index < 2.0 L/min) with right ventricular dysfunction and is treated in an expert center and preferably in the context of a randomized control trial. In the case presented, therapeutic management focused, firstly, on treatment of the underlying heart and lung disease and, subsequently, on specific vasoactive therapy, due to severe hemodynamic deterioration.