Pulmonary hypertension pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Ralph Matar; Rim Halaby José Eduardo Riceto Loyola Junior, M.D.[2]


Pulmonary hypertension (PH) is a pathological condition of the pulmonary vasculature present in several disease states that presents with elevated mean pulmonary artery pressure (PAP) as measured by right heart catheterization at rest. The factors that are in involved in the pathophysiology of the increase in the mean pulmonary arterial pressure are: increase in pulmonary vascular resistance, increase in the right-side cardiac output and increase in the mean pulmonary venous pressure. Pulmonary arterial hypertension is characterized by endothelial dysfunction resulting from an imbalance between apoptosis and proliferation of pulmonary artery smooth muscle cells favoring the proliferation. The other types of pulmonary hypertension are caused by hemodynamic changes that result in increased pulmonary blood pressure or architectural changes to the lung or its vasculature that result in the same outcome.


The pathophysiology of pulmonary hypertension[1][2][3][4][5][6][7][8][9][10]

PH is defined as an elevated mean pulmonary artery pressure (PAP) ≥ 25 mmHg as measured by right heart catheterization at rest. The elevation in PAP results from an elevation in the pulmonary vascular resistance caused by a multifactorial pathogenesis involving genetic and environmental factors.

Pulmonary hypertension has several pathophysiologic mechanisms depending on the underlying etiology. Nevertheless, the following sequence of events is almost always present:

  • Vasoconstriction (ocurring early in the disease);
  • Thrombosis (during the evolution of the disease);
  • Remodeling (then takes place and becomes the most important factor).[3]
    • An initiating factor leads to increased resistance in the pulmonary vasculature causing narrowing of the vessels and impaired blood flow.
    • As a consequence, the right ventricle adapts by increasing right ventricular systolic pressures to preserve the cardiac output from the right heart.
    • Over time, increasing right ventricular systolic pressures will subsequently result in chronic changes in the pulmonary circulation and the affected blood vessels progressively become stiffer and thicker, further increasing the blood pressure within the lungs and impairing blood flow.
    • In addition, the increased workload of the heart causes thickening and enlargement of the right ventricle, making the heart less able to pump blood through the lungs, causing right heart failure. Factors that might affect the ability of the right ventricle to adapt to an increased pulmonary vascular resistance are:
      • Age of the patient at onset
      • Rapidity of onset of pulmonary hypertension
      • Coexisting hypoxemia

Pulmonary Arterial Hypertension

Molecular and Cellular Changes

  • Pulmonary arterial hypertension is characterized by endothelial dysfunction resulting from an imbalance between apoptosis and proliferation of pulmonary artery smooth muscle cells favoring the proliferation.
  • There is also thickened and disordered adventitia due to excessive amounts of adventitial metalloproteinases.
  • Several pathways are implicated in development of vascular remodeling, which is the hallmark of pathologic changes in pulmonary hypertension:

1. Vasoconstriction-mediated remodeling

2. Thrombosis-mediated remodeling

3. Proliferation-mediated remodeling

  • The pathogenic pathway of lung vasculature remodeling in PH is not fully understood;
  • It is regulated by a variety of growth factors, cytokines, mytogens, ion channels, neurotransmitters viruses, transcription factors and receptors, the most studied being the bone morphogenetic protein receptor type II (BMPR2).
  • BMPR2 loss-of-function mutations were found in 70% of patients with hereditary PAH and in 20% of patients with idiopathic PAH;[13][14]
  • Anecdotal reports have stated that imatinib has been able to cause significant improvement of PAH patients;[15]
  • Serotonin exerts both vasoconstrictive and mitogenic effects on smooth muscle cells (SMC).
  • Serotonin m bind to 5-hydroxytryptamine 1A and 2B receptors or may enter SMC via serotonin transporter which induces generation of ROS, rho kinase, and mitogen-activated protein kinases.
  • This in turn leads to the expression of growth factors and proliferation. Bone morphogenetic protein (BMP) is also involved in the SMC proliferation.
  • Upon binding of BMP to its heterodimerized receptors, a group of cytoplasmic proteins known as receptor-mediated Smads are phosphorylated and translocated to the nucleus where they upregulate genes related to anti-proliferation.
  • Serotonin is shown to antagonize the BMP/Smad pathway thus facilitating the proliferation of smooth muscle cells.

4. Inflammation-mediated remodeling

Shown below is an image depicting remodeling in pulmonary arterial hypertension.

Pathophysiology of pulmonary hypertension.png

Genetic Mutations

TGF-β Receptor Pathway

  • The bone morphogenetic protein receptor II (BMPR2) gene encodes a serine/threonine kinase that functions as a receptor for bone morphogenetic proteins which forms a heterodimer cytoplasmic complex of two type II and two type I receptors. The downstream signaling involves activation of SMAD transcription factor which mediates anti-proliferation in smooth muscle cells.
  • Activin-like kinase 1 gene mutations are detected in patients with hereditary hemorrhagic telangiectasia and pulmonary arterial hypertension. Mutation would cause growth-promoting alterations.

Serotoninergic Pathway

  • 5- Hydroxytryptamine (serotonin) transporter mutations have also been associated with the proliferation of smooth muscle cells of pulmonary arteries.[16]


Familial PAH often results from a mutation in the bone morphogenic protein receptor-2 (BMPR2) and is inherited as an autosomal dominant disease with incomplete penetrance and anticipation.[17]

Associated conditions

  • PAH is also associated with:[18]
  1. Congenital heart disease (30% of untreated cases)
  2. Connective tissue diseases (12% of patients with scleroderma and up to 21% of patients with rheumatoid arthritis)
  3. HIV (0.5%)
  4. Portal hypertension (2-6%)
  5. Sickle cell disease (20 to 40%)
  6. Systemic lupus erythematosus (4 to 14%)
  7. Hemoglobinopathies
  8. Myeloproliferative disorders
  9. Drugs and toxins


PH is a pathological condition present in different disease states that share similar clinical manifestation and some common histopathological features. Shown below is a table that summarizes the classification of PH based on histopathology findings.[19]

Class Histopathological findings[19] Images
Pulmonary arteriopathy Constrictive lesions in pulmonary arteries
  • Medial hypertrophy
  • Intimal thickening
  • Adventitial thickening

Complex lesions in pulmonary arteries

  • Plexiform lesions
  • Dilatation lesions
  • Arteritis
Pulmonary hypertension arteriopathy intimal and medial thickening.jpg
Pulmonary hypertension arteriopathy adventitial thickening.jpg
Pulmonary hypertension arteriopathy intimal and adventitial thickening.jpg
Pulmonary arteriopathy with venous-venular changes Changes similar to pulmonary arteriopathy
Changes in venules and veins
Pulmonary hypertension arteriopathy medial muscle layer thickening.jpg
Pulmonary hypertension Plexiform lesion 2.jpg
Pulmonary occlusive venopathy
(with or without arteriopathy)
Changes in venules and veins
  • Diffuse fibrotic occlusion
  • Intimal thickening
  • Medial thickening
  • Adventitial thickening

Changes in the capillaries

  • Dilatation
  • Congestion

Changes in the interstitium

Pulmonary microvasculopathy
(with or without arteriopathy and/on venopathy)
Changes in the capillaries
  • Localized capillary proliferation

Changes in the interstitium

Pulmonary hypertension Pulmonary capillary hemangiomatosis.jpg
Pulmonary hypertension pulmonary capillary hemangiomatosis.jpg
Unclassified Non specific changes


The images below are courtesy of Dr. Yale Rosen (Source:Wikimedia Commons).


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  6. Michelakis ED (June 2014). "Pulmonary arterial hypertension: yesterday, today, tomorrow". Circ. Res. 115 (1): 109–14. doi:10.1161/CIRCRESAHA.115.301132. PMID 24951761.
  7. Douwes JM, Berger RM (February 2011). "The maze of vasodilator response criteria". Pediatr Cardiol. 32 (2): 245–6. doi:10.1007/s00246-010-9849-8. PMID 21110189.
  8. Ranchoux B, Antigny F, Rucker-Martin C, Hautefort A, Péchoux C, Bogaard HJ, Dorfmüller P, Remy S, Lecerf F, Planté S, Chat S, Fadel E, Houssaini A, Anegon I, Adnot S, Simonneau G, Humbert M, Cohen-Kaminsky S, Perros F (March 2015). "Endothelial-to-mesenchymal transition in pulmonary hypertension". Circulation. 131 (11): 1006–18. doi:10.1161/CIRCULATIONAHA.114.008750. PMID 25593290.
  9. Hopper RK, Moonen JR, Diebold I, Cao A, Rhodes CJ, Tojais NF, Hennigs JK, Gu M, Wang L, Rabinovitch M (May 2016). "In Pulmonary Arterial Hypertension, Reduced BMPR2 Promotes Endothelial-to-Mesenchymal Transition via HMGA1 and Its Target Slug". Circulation. 133 (18): 1783–94. doi:10.1161/CIRCULATIONAHA.115.020617. PMC 4856565. PMID 27045138.
  10. Jobe AH, Bancalari E (June 2001). "Bronchopulmonary dysplasia". Am. J. Respir. Crit. Care Med. 163 (7): 1723–9. doi:10.1164/ajrccm.163.7.2011060. PMID 11401896.
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  12. Hoeper MM, Sosada M, Fabel H (1998). "Plasma coagulation profiles in patients with severe primary pulmonary hypertension". Eur Respir J. 12 (6): 1446–9. doi:10.1183/09031936.98.12061446. PMID 9877507.
  13. Momose Y, Aimi Y, Hirayama T, Kataoka M, Ono M, Yoshino H; et al. (2015). "De novo mutations in the BMPR2 gene in patients with heritable pulmonary arterial hypertension". Ann Hum Genet. 79 (2): 85–91. doi:10.1111/ahg.12096. PMID 25612240.
  14. Aldred MA, Vijayakrishnan J, James V, Soubrier F, Gomez-Sanchez MA, Martensson G; et al. (2006). "BMPR2 gene rearrangements account for a significant proportion of mutations in familial and idiopathic pulmonary arterial hypertension". Hum Mutat. 27 (2): 212–3. doi:10.1002/humu.9398. PMID 16429403.
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  18. ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension
  19. 19.0 19.1 Pietra GG, Capron F, Stewart S, Leone O, Humbert M, Robbins IM; et al. (2004). "Pathologic assessment of vasculopathies in pulmonary hypertension". J Am Coll Cardiol. 43 (12 Suppl S): 25S–32S. doi:10.1016/j.jacc.2004.02.033. PMID 15194175.

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