ArcaMax

DEAR DR. ROACH: I took the diet drug Redux in the late 1990s. It was pulled off the market due to correlated heart issues. I saw a cardiologist and learned that I had mild to moderate mitral stenosis with regurgitation. It was watched over a period of years, and they eventually determined that I was stable and had few to no symptoms. So, after a discussion with my cardiologist, we decided to discontinue my visits.

I recently obtained records from this time and two more recent echocardiograms (EKGs) for my new primary care physician. In all of them, they mention I have mild pulmonary hypertension with an ePASP ranging from 40-47 mm Hg. No one has ever addressed this with me. In my search for more information, it seems that an ePASP over 25 mm Hg is of concern. Should this be addressed, or am I needlessly worrying? -- K.T.

ANSWER: Dexfenfluramine, aka Redux (also called "fen-phen" in combination with phentermine), was sold in the 1990s until it was removed from the market in 1997 after valvular heart damage and pulmonary hypertension were found -- more commonly in women.

Thirty percent of people who took the medication for up to 24 months were found to have abnormal EKGs, whereas only 3% of people who took it for three months or less had abnormal heart valves that were found by an EKG. Cases where people have pulmonary hypertension decades after taking dexfenfluramine are still being identified now. Mitral valve disease itself may cause pulmonary hypertension, even apart from the use of dexfenfluramine.

Pulmonary hypertension differs from regular systemic hypertension because it's the blood vessels in the lungs that have high pressure levels. Measuring the pressure in these vessels isn't easy. An EKG can give an estimate (ePASP is the estimated pulmonary artery systolic pressure), but this may not correlate well to an actual measured pressure. This can be definitively obtained by measuring the pressure with a catheter that is placed through the heart into the pulmonary artery during cardiac catheterization.

It's not clear to me that you need to have this done in absence of symptoms. However, pulmonary hypertension is one condition where I refer my patients to an expert. (Both cardiologists and pulmonologists can be experts in the diagnosis and management of pulmonary hypertension.) Since your ePASP is not high enough to be sure of the diagnosis (an ePASP over 5 mm Hg means that pulmonary hypertension is very likely), it takes judgment to decide whether cardiac catheterization is necessary.

I spoke with a colleague, Dr. Maria Karas, who is an expert in pulmonary hypertension. She noted that a cardiopulmonary exercise test (or possibly a stress EKG) might help decide whether a cardiac catheterization is appropriate. It may be that your cardiologist has considered this carefully and decided that pulmonary hypertension was unlikely, but I really think that this should have been an explicit decision made with you, to avoid you being in the situation you're in now. It's worth a conversation with your cardiologist.

You may also consider finding an expert in pulmonary hypertension through the Pulmonary Hypertension Association at PHAssociation.org.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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