LAUSR

For physicians in my generation, pulmonary hypertension was a condition resulting from ignored congenital heart disease, chronic obstructive lung disease, and thromboembolic disease, generally acute, or (most patients) unknown. von Romberg [1] first described pulmonary hypertension, although he could not measure pressures. Experimental models enhanced understanding [2]. The first clinical review to my knowledge was published a few years before I was born [3]. An explosion into pulmonary hypertension has occurred far more recently. The condition now has an orderly classification according to causes and associations. Particularly vexing is group IV, termed chronic thromboembolic pulmonary hypertension (CTEPH). In this issue of Trends Cardiovascular Medicine, Robbins et al. [4] give us a timely update on CTEPH. They grace their review with seven helpful figures that translate for the readership the current status of CTEPH. What can be added here? Since, stethoscopes have turned into neck decorations, the diagnosis of pulmonary hypertension relies on echocardiography. But then, the diagnostic searches for causality begin. The six WHO definitions have made matters more precise. How can we select the patients with CTEPH from the numerous other patients with pulmonary hypertension? I would have thought that modern CT would have relegated nuclear medicine (we used to call it unclear medicine) into the dustbin as it has for acute pulmonary embolism. However, that event has not yet happened. As the authors indicate, and as underscored by others, CTEPH is still under-diagnosed, mainly due to the insufficient use of ventilation/perfusion (V/Q) scanning in patients with pulmonary hypertension [5]. Stricker points out that with a negative predictive value of Z98%, a sensitivity rate of Z96%, and specificity rate of Z90% for the detection of CTEPH, the