Top Things to Know: Evaluation and Management of Pulmonary HTN in Non-Cardiac Surgery

Published: March 16, 2023

  1. Pulmonary hypertension (PH) is defined as an elevation in the blood pressure of the pulmonary arteries with a mean pulmonary artery pressure > 20 mmHg. Some forms of PH can result in right heart failure with significant morbidity and mortality.
  2. The prevalence of PH is increasing with an aging population with concomitant heart and lung disease, and more patients with PH are undergoing non-cardiac surgery.
  3. PH is associated with an increase in perioperative morbidity and mortality, with increased risks of heart failure, cardiac arrhythmias, hemodynamic instability, respiratory failure, prolonged ventilatory support, and intensive care utilization.
  4. A team-based approach is critical to the care of PH patients undergoing surgery and should include a PH specialist, anesthesiology, surgery, and other teams as needed based on the patient’s underlying risk factors.
  5. A multistep process is advocated: 1) classification of PH group to define the underlying pathology; 2) preoperative risk assessment that will guide surgical decision-making; 3) PH optimization before surgery to reduce perioperative risk; 4) intraoperative management to avoid right ventricular dysfunction and maintain cardiac output; and 5) postoperative management to ensure recovery from surgery.
  6. The clinical classification of PH includes group 1 (pulmonary arterial hypertension), group 2 (PH associated with left heart disease), group 3 (PH associated with lung disease), group 4 (PH associated with pulmonary artery obstructions), and group 5 (PH with unclear and/or multifactorial mechanisms). The treatment of each PH group is based on their underlying cause for PH.
  7. Preoperative risk assessment should include global physical status, pulmonary-, cardiac-, PH-, and other disease-specific risk assessments as needed based on the patient’s medical history.
  8. Optimization of PH should occur before surgery. In the setting of elective surgery, this includes optimization of PH medical therapy and general cardiopulmonary status. This may not be possible in the emergency setting, where the focus is on ensuring the stability of the right heart and end-organ perfusion during surgery.
  9. Intraoperative management includes choice of anesthesia, intraoperative monitoring, and a focus on ensuring stable RV function and end-organ perfusion with the use of selective vasodilatory therapies and vasoactives as needed.
  10. In the postoperative setting, patients may recover quickly aftercare in the post-anesthesia care unit (PACU) while others may require critical care due to complications from surgery or right heart failure.


Rajagopal S, Ruetzler K, Ghadimi K, Horn EM, Kelava M, Kudelko KT, Moreno-Duarte I, Preston I, Rose Bovino LL, Smilowitz NR, Vaidya A; on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, and the Council on Cardiovascular and Stroke Nursing. Evaluation and managementof pulmonary hypertension in non-cardiac surgery: a scientific statement from the American Heart Association [published ahead of print March 16, 2023]. Circulation. 2023;147:e•••–e•••. doi: 10.1161/CIR.0000000000001136