High Blood Pressure in the Lungs – Get the Facts from National Jewish Health

Did you know that you can develop high blood pressure in the lungs? It’s called pulmonary hypertension or PH. It is rare, but is a serious condition. Find out what you need to know from PH expert, Patty George, MD, in this QA session.


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Alyssa Paschke: Hi everyone, and welcome to our May Live Q&A. Today, we're going to discuss pulmonary hypertension, which, in broad terms, means high blood pressure in the lungs. Although it's a
rare condition, it can be serious and can often be misdiagnosed. So, today, I'm speaking with Dr. Patricia George. She's a pulmonologist at National Jewish Health and Saint Joseph Hospital. Her work includes the diagnosis and treatment of pulmonary hypertension, and research to better understand the disease, and someday, hopefully, find a cure.

Alyssa Paschke: If you have a question as we go along, feel free to type in the comments, and we'll try to get to as many as possible. So, thanks so much for joining us this afternoon. I wanted to start off with asking you about what is pulmonary hypertension. Some folks out there may know about it, some folks might not be familiar at all. So, if you could just start with what is it and are there different types?

Dr. George: Yeah, sure. So thank you so much for having me today. I'm really excited to be talking, especially as this is the week of pulmonary hypertension, World PH Day. So it's a good time for us to be discussing this. Pulmonary hypertension, as you mentioned, means high blood pressure in the arteries of the lungs. That's sort of a big global definition of what PH is. But there are several different types of pulmonary hypertension, and we'll get to that in a second.

Dr. George: Symptoms of pulmonary hypertension, like how it might look, is it presents with people being short of breath, and usually it starts out with feeling shortness of breath or fatigue with exertion or with exercise. Sometimes, as it progresses, people can have swelling from heart failure type symptoms. They might feel lightheaded when they exert themselves, and sometimes some people have chest pressure and some other symptoms.

Dr. George: Part of the difficulty with pulmonary hypertension is the symptoms of PH look a lot like other lung diseases, and so it can make it difficult to diagnose. There are different types of pulmonary hypertension. If you go online and do a web search, most often, you get the information about pulmonary arterial hypertension, and that's where you have high blood pressure in the arteries of the lungs from stiffness, or a disease of the pulmonary arteries themselves.

Dr. George: For that, we have many different medications, 14 FDA approved medications, to help open up, dilate those pulmonary arteries, and help people breathe easier. There are other types. The second type of pulmonary hypertension is PH due to left sided heart disease. So, as I explain to my patients often, we go through the whole circuit of how blood flows through the body. Blood goes to the lungs to get oxygen and then it goes to the left side of the heart to be pumped out to your organs, your tissues and supply oxygen. If that left side of the heart doesn't pump well, or maybe it pumps well but doesn't relax properly, or you have leaky valves or something like that, you can get back up pressure into the lungs.

Dr. George: The third type of pulmonary hypertension is pulmonary hypertension due to lung disease. So, that can be chronic low oxygen levels, like untreated sleep apnea, or untreated emphysema, or pulmonary fibrosis, and those diseases can also cause pulmonary hypertension. We certainly see a lot of that here at National Jewish Health.

Dr. George: The fourth type is pulmonary hypertension due to chronic blood clots. People can get pulmonary embolism, and most of the time, when you treat that with blood thinners, it goes away. But in some patients, it turns into scar tissue, and that can present a blockage in the pulmonary artery, and turn into pulmonary hypertension in some people.

Dr. George: Whenever we have categories, you always have a catchall category, a miscellaneous. That's like rare lung diseases or diseases that don't quite fit into the other categories, like sickle cell disease or other things are in that group five category. So, when I see somebody in clinic and trying to make the diagnosis, I try to say, "Okay, do they have pulmonary hypertension? If so, which type?" Because depending on what type you have, we treat each one very differently.

Alyssa Paschke: Interesting. So it's kind of an umbrella term, pulmonary hypertension. And then, it's really complex as far as what type you have and then the treatment off of that. Okay. So, that definitely is very helpful. I know you mentioned symptoms a little bit.

Dr. George: Yeah.

Alyssa Paschke: What are some of the risk factors that people might have for developing pulmonary hypertension?

Dr. George: To look at that, we really should talk more about the first type, the pulmonary arterial hypertension. It's not a smoking related lung disease, it's not like some of our other lung diseases. And then, if we break it down into risk factors, we would talk about, of the people that have pulmonary arterial hypertension, what types do they have? So, within that category, the most common type is what we call idiopathic pulmonary arterial hypertension, or IPAH. And that's due to causes we're still trying to figure out.

Dr. George: There are also patients who develop a heritable form, so it can run in families due to genetic mutations. And sometimes the idiopathic patients have those mutations as well. Then you get into the second most common type, is connective tissue disease associated pulmonary arterial hypertension. So PAH is not that common. It's a rare disease in the United States, which means that there's less than 200000 people in that in the country that have PAH.

Dr. George: But if you have certain other conditions, you're at higher risk of getting it. And idiopathic pulmonary hypertension is about 5 in 1 million, something like that, of the whole population. But, if you have a condition such as Scleroderma or connective tissue disease, auto immune disease, you may be at higher risk. Of those patients, more of them may get pulmonary arterial hypertension. If you have HIV, the prevalence is 1 in 200, so there are certain other diseases, people who have cirrhosis and portal hypertension from cirrhosis or liver disease are also at risk for perhaps developing pulmonary hypertension. So, there are these subgroups that can certainly be more predisposed.

Alyssa Paschke: That makes sense. And so it's not necessarily a lifestyle factor, it's more of the underlying disease that you might have. So to talk a bit more about the symptoms, I know you mentioned shortness of breath, especially with activity and also swelling. What are some of the symptoms that are hard to differentiate between other lung diseases, like you mentioned? So, someone could present with certain symptoms. How do you go about accurately diagnosing the symptoms, because it could be other diseases?

Dr. George: I think the most important thing about making the diagnosis of pulmonary hypertension when you're a doctor or a nurse, nurse practitioner, somebody seeing these patients on the front lines, is that we have to have it on our radar. If you don't think about it, you're not going to do the appropriate testing to screen for it and make the diagnosis.

Dr. George: And that comes down to also being precise when we make a diagnosis for somebody's shortness of breath. If somebody presents to a clinic, and they have shortness of breath when they exert themselves, that's a common thing. It could be asthma, it could be being out of shape, it could be COPD, it could be pulmonary hypertension. Most commonly it will be the common diseases. There's a campaign through the Pulmonary Hypertension Association, called Sometimes It's a Zebra. That comes off of the saying that we used to say in medical school. Like when you're learning things, and you're coming up with your list of diagnoses. When you hear hoof beats, you should think horses, not zebras, because most commonly it's going to be the horse. But pulmonary hypertension is a zebra diagnosis. You have to at least think about it.

Dr. George: Well, if you're a person out in the community and these people are presenting, I think it's important to make sure we're getting data. So, if we think it's asthma, let's make sure there's pulmonary function tests before we just treat. And if we do institute a treatment like an inhaler, broncodilators, etc., it's important to follow up with those patients and make sure that they're getting better, not worse. Because if they are, then it may not be the asthma, or it's more complicated, it's pulmonary hypertension, right?

Dr. George: So, I think that's really important is to have that index of suspicion. And if you do, and if they do have these symptoms, again, shortness of breath when people exert themselves, fatigue, a lot of times people are just really tired, wiped out, especially if they have a day where they go do a lot, the next day they might be really tired. Of course swelling, lightheadedness, etc., can go on with it.

Dr. George: So, if they have those symptoms and it doesn't really look like asthma, COPD, the other common things, or they have swelling and you can't explain it. Then the screening test of choice is to get an echocardiogram, which is an ultrasound of the heart. With pulmonary hypertension, we can't put a blood pressure cuff around the arteries of the lungs. It's just not possible. The same way you can measure regular blood pressure, and they're totally different. And so we use ultrasound and look at how blood flows through the right side of the heart, which leads to the lungs, because the pressures are reflected there often. And so, that's usually our screening test of choice.

Alyssa Paschke: Got you. And so along with the screening tests, we received a question earlier today, by Ruby S., and she was wondering why is CPET used to diagnose pulmonary hypertension?

Dr. George: Ooh, okay. That's one of my favorite tests. It's used as part of the diagnosis. This is how I use it, and how we use it here, often, at National Jewish. When we see people who come into us, like I mentioned, people most often, when they start out, have symptoms when they're exerting themselves, when they're exercising, but not when you're at rest. And sometimes we have patients, especially here, but at a lot of academic centers, or even in the community, you have patients who, they're not just clean, "Oh, this is clear cut pulmonary hypertension. They may actually have a bit of pulmonary function abnormalities, a bit of asthma, a bit of COPD. So you're trying to tease out what's exactly causing the problems.

Dr. George: One of those tests that we employ, especially when we're looking at patients, is we say, "Well, okay, this is you sitting still, but what happens when you exercise? What happens to your physiology?" One thing we can do is treat them like an athlete and put them on a bicycle, and then have them pedal to as far as they can go. When we do that, they have this mask that they have, and we measure how much oxygen their body consumes, how much CO2 they produce. We look at their heart rate, we look at their respiratory rate, their lung volumes, all of these very neat variables.

Dr. George: There are certain patterns that you can see that fall in line with, maybe, pulmonary hypertension, maybe COPD, maybe neuromuscular weakness, because they have fatigue when they're fatigued. If you have undifferentiated disease, you can help distinguish that. Plus, it's a test that you can do, and then put people, let's say they do end up having PAH, then down the line you could retest and see if they've improved certain variables on their exercise test.

Alyssa Paschke: And to see if their treatment plan is working.

Dr. George: Mm-hmm (affirmative). So, it's one of the things that some centers will use looking at pulmonary hypertension.

Alyssa Paschke: Okay, great. Well thanks for that question.

Dr. George: That's great.

Alyssa Paschke: I wanted to pause and see if any other questions have come in from the audience so far.

Jessica Fish: So, Coco B. did ask, how do you tell between COPD and pulmonary hypertension, which you kind of went into.

Dr. George: Yeah, great question. So, how do you tell between COPD and pulmonary hypertension? COPD, that's chronic obstructive pulmonary disease. That's a disease of the airways. Typically, that's diagnosed with pulmonary function tests. Those are the tests where you come and you go to a machine device, and you blow, blow, blow, and they cheer you on, and you try to empty your lungs as fast as you can. And there are certain patterns that you see, a ratio per se, and we can measure that there.

Dr. George: It's a little more fine-tuned than that, but we use, a lot, the pulmonary function tests, maybe a CT scan to look for emphysema. Pulmonary hypertension is different. We use those tests because we're trying to exclude lung disease as being the driver or figure out, again, what category do people fall into. But with pulmonary hypertension we make the diagnosis based on Echo, the screening test, but ultimately, and very importantly, that's not how you make the true diagnosis. You have to go forward and do a right heart catheterization plus all the other testing of course.

Dr. George: But the right heart catheterization, so that's a right sided heart catheterization, which is a procedure where we actually, again, because you can't put a blood pressure cuff around the arteries of the lungs, you have to go in and measure it from the inside. It's an outpatient procedure done in the Cath lab where you numb up a small area in the artery in the neck, and then insert a catheter that goes down through the right side of the heart and out into the pulmonary artery. And we can get really fine-tuned measurements.

Dr. George: That, in addition to all the other testing, helps us really help decide do they have PAH? If so, what type? And now, what therapies would be the best to start.

Alyssa Paschke: And being able to differentiate it from the other conditions. Okay, great question. Anything else?

Jessica Fish: Yes, Cindy W says, "Are there findings on a relationship between PAH and Sjögrens?

Alyssa Paschke: Oh, Sjögren's?

Jessica Fish: Sjögrens.

Dr. George: Great. Yes. Okay. So, the question is, are there findings of an association between pulmonary hypertension and Sjögren's? Yes. So, I mentioned how there are certain groups of patients that may be at higher risk for developing pulmonary hypertension. One of those groups of patients are the patients who have autoimmune disease, or we call it connective tissue disease, that's another, or rheumatologic disease. So you might hear any of those words used.

Dr. George: Then, in that, you have diseases like the most common that people hear about is probably Lupus or rheumatoid arthritis, less commonly heard about, but certainly fairly common, are diseases like Sjögren's or a Scleroderma, which is very commonly associated with pulmonary hypertension and interstitial lung disease.

Dr. George: Then there are other diseases as well, like polymyositis or dermatomyositis. So, there are many diseases in this category, and part of what do at National Jewish Health, and at other centers as well, is that we work very closely with the autoimmune doctors, the ones that we call rheumatologists, as we're trying to really tease out how to treat the diseases.

Dr. George: If patients come and they have those autoimmune diseases, especially Scleroderma or mixed connective tissue disease, or undifferentiated connective tissue disease, then we know that we should get a screening echocardiogram, have a really low threshold to look for it, so that we make a diagnosis as early as possible. It's something that doctors will often monitor for, either the rheumatologic doctors or they'll send them to us, and we'll help monitor as well.

Alyssa Paschke: Okay. And I think that question is a great segue into talking about the pulmonary hypertension center between National Jewish Health in Saint Joseph Hospital, and the multidisciplinary approach that you're taking to these patients, since it is such a specific disease, and you're trying to rule out everything else that it could possibly be. Could you talk a little about what the patient experience is with the center and how that works?

Dr. George: Oh, absolutely. At National Jewish Health, we have many specialists and sub specialists, and sub-sub specialists in lung disease. I'm a lung doctor. I'm a pulmonologist by training, but my focus is, of course, pulmonary hypertension. But there are other lung doctors here who focus specifically on COPD, interstitial lung disease. And there are other doctors here, like cardiologists, rheumatologists.

Dr. George: What we try to do in our program is utilize, we call it, the fancy word is multidisciplinary. But what we mean by that is we really try to put together a team, like a team of specialists who can come together around the captain of the team, who's the patient. That's the whole focus. So, when someone comes in with shortness of breath, could be pulmonary hypertension of whichever category. Then oftentimes, I'm getting involved and one of my cardiology colleagues in the pulmonary hypertension clinic is getting involved.

Dr. George: Both of us might see the patient initially, or one of us might, and then we're certainly discussing the patient with one another. And certainly our cardiologists are also involved in doing a lot of the testing from interpreting echocardiograms to performing the right heart catheterization, specifically with Dr. Kim over at Saint Joseph Hospital.

Dr. George: The other parts of the team, however, are our doctors who specialize in sarcoidosis, in interstitial lung disease, in occupational lung disease, in COPD, and of course the rheumatologists, so if we have these patients who are very complicated, then those people are also part of the team, as are the sleep doctors, etc. So, that's what we mean by this team or multidisciplinary approach.

Dr. George: Also on that team, very importantly, and probably the most important, is our nurses. It's nurses week, and our nurses are the front line in terms of reaching out to our and really getting to know them. So they're very, very important, as are our nurse practitioners, who see people very frequently, and help shepherd them through the process as well.

Dr. George: When we talk about Saint Joseph Hospital, so some of our patients, depending on the severity, they go there for their testing, for the right heart catheterization. Other stuff's done here mostly. But once that's done, if they're sick and need to go on very potent therapy or IV therapy or we call it parenteral therapy, but it means IV or continuous therapy that you get through a pump, through a catheter that goes into your vein, or through the skin, like an insulin pump for a diabetic.

Dr. George: If they need that kind of treatment, or if they're sick, they go to Saint Joseph Hospital. And over there, we have a team and a floor of nurses who really understand the medications, know what to look out for in our patients. And they actually ended up getting to know our patients as well, especially in asking after them, long after they've left the hospital. That's a bit about our nature and our culture.

Alyssa Paschke: And so that's really good for anybody out there who may be unsure of their diagnosis or maybe already have pulmonary hypertension, are looking for treatment options. You're in very good hands with a lot of different specialists and people that are all working together to make sure that your treatment plan is the best possible. So, that's really great information. I had a question come in before our time today from Linda H., and she asked, "Can pulmonary hypertension resolve or become a minor problem because of AFIB?"

Dr. George: Ooh, good question. You guys have great questions. I love this. So, AFIB makes things complicated. Atrial fibrillation is really fairly common, much more common than pulmonary hypertension. And very few of those people end up having pulmonary hypertension. In a very rare instance where patients have had multiple ablations of AFIB, where they go in and zap inside the heart, sometimes people can get scar tissue, and sometimes that can cause, this is rare, so you don't necessarily have to go pick up the phone and, "Oh my gosh, I have this."

Dr. George: So, this is rare, but people can get a condition that's associated with post-afibrillation, where they can get high pressures in the lungs. When patients have pulmonary hypertension and atrial fibrillation, we work really closely with our electrophysiology doctor, Dr. Sung, because in general, patients with PAH, like to have their heart rate controlled, obviously, or maybe not obviously, but it's good when it's in a normal rate. It's even better if it's a normal rhythm. So, we work pretty closely together to give their heart as much as we can, which includes sinus or normal regular rhythm as well.
Alyssa Paschke: Great. And just for everyone out there, we did interview Dr. Sung a couple of months ago. So, you can check out that video about AFIB specifically on our Facebook page. So, just wanted to let everyone know that additional information is available. Lauren H. asked, "If your MRI numbers indicate pulmonary hypertension, are the current ways to measure those numbers efficient enough, or is there additional testing? I think is what she was asking, that's required.

Dr. George: Good questions. Some patients get cardiac MRI. When you have pulmonary hypertension, both in the diagnosis phase and also in the follow-up phase. So patients who get diagnosed go on therapy, we're following them very frequently, and getting regular clinic visits. So, it's important for us to know are you feeling better? Is your shortness of breath better, are your symptoms approving? That's the most important thing.

Dr. George: It's important to know from the patient, of course, what their goals are, so that we can help them achieve those goals. Whether it's, "Oh, I want to be able to walk in the neighborhood." Or, "I want to be able to go to my daughter's, or my granddaughter's soccer games and feel okay." Whatever it may be, we want to help those people do that.

Dr. George: So, there's those, but then there's also tests that we do at each visit, and some of those tests are: Echocardiogram every six months, sometimes more frequently, if we think something's going on. Cardiac MRI can be, often very useful. Cardiac MRI is just a higher definition. It's complimentary. It doesn't replace echocardiogram. It's a longer test, and you have to not be claustrophobic because it's a narrow tube, and you have to be able to lay flat and then go through that.

Dr. George: But it can give us a bit higher definition of what does the ejection fraction, what's the size of the right side of the heart and the left side of the heart, the whole. You can really look in high definition. Also, what's the ejection fraction? How is it pumping? And so we can use that. We might do it every year in patients just because of the expense, not the expense in terms of money. I often think about it in terms of patient expense. Like how much can they invest in testing?

Dr. George: Not money, but their time and what they're going through. So, you have to balance all of that. We may do that once a year with also echocardiograms. It doesn't replace measuring the pressures. So, when you do imaging studies, and measuring the pressures doesn't replace getting an echocardiogram, or if you have access, a cardiac MRI. And so you have to really look at both because, and patients will ask this, which is a great question, you need to know what the pressures are, but you also need to know what the heart looks like and how it's dealing with the pressures. You basically need all of the tests to see that.

Alyssa Paschke: Got you. That definitely makes sense to look at the whole picture. I wanted to pause one more time and see if we have any other questions that have come in from the audience.

Jessica Fish: Yes we do. Kate E., is asking about secondary pulmonary hypertension, and is there treatment

Dr. George: Yes. Okay. So, secondary pulmonary hypertension. We now call it different things. There used to be a term called, and this was a few meetings ago, and some people still use this term, so it's still used, so it's important to talk about this. So, very good question.

Dr. George: People used to call pulmonary arterial hypertension, primary pulmonary arterial hypertension, and then you could have secondary pulmonary hypertension. So, when we talk about primary, or when we talk about PAH, now we really talk about it in these terms. So, we talk about pulmonary arterial hypertension, which can be idiopathic, like I said before, or heritable, meaning it runs in families, or connective tissue disease or HIV, or those sorts of things. So that's in your PAH category.

Dr. George: When you talk about secondary, that's pulmonary hypertension associated with lung disease, for example. That might be patients who have COPD and have PAH, or who have emphysema and PAH, or interstitial lung disease and PAH. It's a lot harder to treat that, or it's different in how we treat it. And it also depends on the severity of the disease. So, the guidelines tell us, and accurately so, that the way that you're supposed to treat patients who have associated PAH, like lung disease associated PAH, it's also called a group three, or World Health Organization Group Three, those patients, the primary thing that you want to do is you want to treat the underlying disease.

Dr. George: So, you want to make sure that if they have interstitial lung disease, maybe it's hypersensitivity pneumonitis, we need to go attack that and try to quell the immune system. Maybe it's COPD, so they need to be on oxygen, and make sure they're not walking around with low oxygen levels. They need to be on the inhalers, need to go through pulmonary rehabilitation. So, all these things that we can do to optimize as much as possible, the underlying lung condition is crucial.

Dr. George: That includes treating nighttime, low oxygen levels or nighttime obstructive sleep apnea. So, all that is really essential. There are some patients, and this is where science, and this is where some of our research is heading, where patients might have a bit, like a very mild degree of lung disease, but we measure their pressures and it's very, very severe. So, almost not enough lung disease to perhaps treat with an inhaler, and very, very severe.

Dr. George: And when we meet in the World Symposium of Pulmonary Hypertension every five years, that's where all the experts get together, they always talk about this group because it's more common than the PAH group. You see a lot more people with COPD, interstitial lung disease, pulmonary fibrosis. So, what do we do with these people?

Dr. George: And we've had numerous clinical trials that have shown that just traditional use of treating these people is not only not helpful, but even harmful. So we can't just use our medications for the PAH in the lung disease patients. That's very important, because we could make them worse.

Dr. George: But with that, our research is, we're trying to figure out are there some people that might benefit, because maybe the proportion, we used to call it disproportionate PAH, like more than you would expect for a mild degree of lung disease, etc. And there are clinical trials that were participating in here, as well, to try to help define that. So it's an area of research.

Dr. George: It shouldn't be done if you do have PAH associated with lung disease, it's really important to go to an expert center. You don't just treat everybody. It has to be a highly defined group of people. It's important to go to that expert center, where they can really delve into doing the tests, like the cardiopulmonary exercise test and all of that stuff. Or even a right heart catheterization with cardiopulmonary exercise test, which we'll sometimes do in the Cath Lab, to really try to dissect out is this something that we should or shouldn't do? Most often we shouldn't. Most often we just send them or focus on treating their lung disease, primarily.

Alyssa Paschke: That's really good information to know, and thanks for that question. So, to talk a little more about research and clinical trials, I wanted to ask you some of the research that you're involved in. Can you describe that a little bit more? And then is there a way for patients to get involved with the research?

Dr. George: Absolutely. Part of what we do at National Jewish Health is, in addition to taking care of complex patients, is we're really trying to figure out more about the disease. And here, one of the reasons I came here was because of our wealth of patients who do have complex lung disease. Because that's, I think, a field where we really want to make some advances, and help those people with the associated or the secondary pulmonary hypertension.

Dr. George: So, we're involved in several clinical trials here. Some are in there, and we try to lay out a smorgasbord, so that we're not competing with one patient, "Oh, you need to be in five trials." That doesn't work. And also so that we can offer as many patients as possible once they're maximized on whatever you would normally give somebody.

Dr. George: "Well, in addition, here's a research trial. This might give you access to a novel molecule, or something that could help treat your pulmonary hypertension." Of course, a lot of these trials have placebo, and so that's why you would never replace standard of care with a clinical trial.

Dr. George: We have several of those looking at medications, both in the PAH category, patients who have connective tissue disease. We have a trial looking at using an inhaled medication in patients with pulmonary fibrosis, who have pulmonary hypertension. We have a couple of trials that are looking at new molecules.

Dr. George: Our current medications function mostly by helping relax the pulmonary arteries. But the field's in the direction of trying to figure out why do you have the disease to begin with? Is it an immunologic problem? Is there inflammation on some level, or an autoimmune type thing on some level that's driving it. So, there are these molecules that have been designed, that we are using to try to see if that helps treat the underlying problem that might be fueling the pulmonary arterial hypertension.

Alyssa Paschke: Great. So, I think that's really important to know that there are some advances that are going on to try and treat this complex disease, that has a lot of different types, and really kind of get the diagnosis on the one hand, and then also be on the forefront of treatments.

Dr. George: And one of the really important things that we're doing, is we've established a registry, and are now enrolling in a registry here, and that's basically anybody who passes through, if they give us permission, that allows us to just capture their data over time. So, we can see what happened. When we treat people clinically, who gets better, who progresses and sort of see how that works out.

Dr. George: That will help us, hopefully, help the next patients, and people not only here but elsewhere as well. In terms of getting involved, if people want to get involved, they can certainly reach out to us and email us at National Jewish, or look on our website for research opportunities available. Ours are still getting updated with the latest clinical trials in PAH, so they're not all there. I think we have six or seven right now, so they're not all posted, but they will be soon.

Dr. George: The other thing, though, is our audience probably has people who are from not just around Denver, given that it's Facebook, and so there's a really cool app. If you are out there in the audience and you have pulmonary hypertension, and you want to get involved in research, you would do a couple things. Number one, talk to your physicians. Make sure that you're involved with your PAH doctor, your PAH specialist.

Dr. George: Number two, you can go online to a website, PAHaware.global, and they've created this really slick survey that you can basically fill out, and it helps, because there are so many clinical trials, and some are for connective tissue disease, some are for idiopathic group, one some are for lung disease, etc. You only will have one of those conditions, presumably. So, in order to find the trial that best fits you, this app helps you program in your status with very simple questions, and then it will show you the trials that are close to you. So, if you're interested in getting involved in research, check it out and see if that's useful.

Alyssa Paschke: Great. And that's an awesome resource that we will post in the comments on this video, if anybody out there is interested. I just wanted to pause for one last time to see if any other questions have come in.

Jessica Fish: Yes, we have had a couple people ask about sleep apnea and hypertension. Dr. George: Sure. Untreated sleep apnea can def... Well, and hyb... So her question, sorry, she doesn't have a microphone, said that some people have asked about untreated sleep apnea and hypertension. So, there's an association of... Or you do have a microphone. Excuse me. I didn't see you. I just repeated everything. It's hidden.

Dr. George: There is an association of sleep apnea with regular hypertension, like poorly controlled, regular systemic hypertension. There also is an association of untreated sleep apnea with pulmonary hypertension. When people have sleep apnea, their process is, of course they go to sleep, and their muscles that keep open their airway, mainly the tongue muscles, relax. And sometimes, what can happen is, it can block off the airway transiently. So, what happens is, you get low oxygen levels, and the brain's like, "Hey, this isn't working so well." So, you have these micro awakenings, not the kind of like, "Oh I'm going to get up and go get a drink," and that sort of thing. But you have these micro awakenings, and sometimes people can have this 40 times an hour, 100
times an hour. And sometimes not even that often.

Dr. George: Every time that happens and the oxygen levels go low, the pulmonary arteries kind of constrict, so it can exacerbate, and sometimes, if it's severe, untreated sleep apnea, provoke that. So, it's something that you definitely don't want to leave as a stone unturned. We often talk about sleep studies and try to get those studies done as part of the workup, because that certainly is something important to treat, if it's present.

Alyssa Paschke: Well, great question. Thank you all so much, and I think we're a little bit over time, so I wanted to wrap it up for now, but if we didn't get to your question or if you thought of a question after we're done here, feel free to post it in the comments, and we'll send it over to Dr. George to answer.

Alyssa Paschke: We really hope that this conversation was informative for everyone. It definitely was for me, to learn more about this condition, and how National Jewish Health and Saint Joseph Hospital work together to treat this rare condition, but very serious, and that there's research, and other things going on behind the scenes to help progress awareness and treatment moving forward.

Alyssa Paschke: So, thank you to the audience. Thanks, again, to Dr. George. And if you'd like to learn more information, you can visit workingtogether.org/ph, and that will give you a lot of information about the condition and National Jewish Health and Saint Joseph Hospital, and that's workingtogether.org/ph. Thank you.

Dr. George: Thank you.

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