Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association | Circulation
Portal Hypertension Symptoms & Their Most Common Complications
Portal Hypertension Symptoms and Their ComplicationsPortal hypertension is a condition in which increased pressure within the portal vein—an important vessel that carries blood from the stomach and intestines to the liver—rises beyond normal levels. This rise in pressure often occurs due to advanced liver disease, particularly cirrhosis. Cirrhosis causes the liver to develop scars that replace healthy liver tissue, which makes it difficult for blood to flow freely through the organ. When that primary route of blood flow becomes blocked or narrowed, pressure in the portal vein begins to climb, forcing blood to divert into smaller blood vessels. Over time, these smaller vessels can swell under the added load, eventually leading to various complications [1].
Table of Contents
Causes of Portal HypertensionPortal hypertension can be caused by various factors, including liver disease, blood clots in the portal vein, blockages of the veins that carry blood from the liver to the heart, schistosomiasis, and focal nodular hyperplasia. The most common cause of portal hypertension is cirrhosis of the liver, which is scarring that accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage.
How the Portal Vein Works
Esophageal varices and and illustration of a portal vein.
(Alila Medical Media)
The portal vein plays a central role in transporting nutrient-rich blood from the digestive organs straight to the liver. There, the liver filters out toxins and processes nutrients. Increased portal blood flow, driven by vasodilators and shear stress, contributes to the buildup of pressure in the portal vein. When it is scarred by cirrhosis, it is no longer an open highway for blood flow. This buildup of pressure is often first noticed by signs such as fluid accumulation, swelling of veins in the digestive tract, or changes in organ function.
Risk FactorsRisk factors for developing portal hypertension include chronic liver disease, family history of liver disease, viral hepatitis, and alcohol abuse. Regular monitoring and follow-up with a healthcare provider can help detect portal hypertension early and improve outcomes.
Clinical Signs and SymptomsThe main symptoms and complications of portal hypertension include ascites (fluid buildup in the abdomen), dilated veins or varices, and bleeding from varices. Doctors make the diagnosis of portal hypertension based on the presence of ascites or dilated veins or varices as seen during a physical exam of the abdomen or the anus. Various lab tests, X-ray tests, and endoscopic exams may also be used to diagnose portal hypertension. Symptoms of portal hypertension may not always be present, but when they do occur, they can include abdominal swelling, vomiting of blood, and lab abnormalities such as elevated liver enzymes or low platelet counts.
Major Complications of Portal Hypertension
Vector medical illustration of normal liver and cirrhosis with portal hypertension.
(FuHonra)
Portal hypertension can affect many parts of the body. Bleeding varices are one of the significant complications of portal hypertension. Below are the most significant complications that arise when the portal vein remains under high pressure over extended periods.
Varices (Enlarged Veins in the Digestive Tract)What Happens? When blood cannot pass smoothly through the scarred liver, it flows into smaller veins near the esophagus and stomach, causing these veins to grow larger than normal [1]. This is somewhat similar to having a clogged pipe in a plumbing system: the backup of pressure forces fluid into adjacent, more fragile channels. These swollen veins are called varices, and complications such as bleeding varices can arise from them.
Symptoms
An episode of variceal bleeding is considered an emergency because it can lead to rapid blood loss.
Treatment and Prevention
Regular checkups, including periodic endoscopy, are often recommended to monitor for new or recurring varices.
Ascites (Fluid Buildup in the Abdomen)What Happens? Ascites refers to the accumulation of fluid in the abdominal cavity. As increased pressure in the portal venous system rises, it disturbs fluid balance in the body. The liver can no longer regulate the flow of salt and water properly, causing fluid to leak from blood vessels into the belly [1].
Symptoms
Treatment
Ascites is a strong indicator of advanced liver disease and should not be ignored. Frequent medical monitoring can help avoid complications such as infection of the ascitic fluid.
Hepatic Encephalopathy (Brain Dysfunction Due to Toxins)What Happens? A key function of the liver is to eliminate toxins such as ammonia from the blood. When it is damaged, these toxins linger, eventually traveling to the brain and disrupting its normal activities. This condition is called hepatic encephalopathy [3].
Portal hypertension can also lead to an enlarged spleen, which decreases the count of white blood cells, increasing the risk of infections.
Symptoms
Treatment
Early detection of hepatic encephalopathy is vital because therapy can often reverse the mental changes and improve overall well-being.
Hepatopulmonary Syndrome (Lung Problems Due to Liver Disease)What Happens? In advanced liver disease, blood vessels inside the lungs may expand, affecting how oxygen enters the bloodstream. This phenomenon is known as hepatopulmonary syndrome [4]. Increased pressure in the hepatic vein contributes to the symptoms by causing blood flow obstruction and the development of collateral circulation. Individuals may notice they become short of breath more easily, especially when upright.
Symptoms
Treatment
Diagnosis often requires specific imaging tests and measurement of oxygen levels. People with advanced liver disease should promptly report any persistent breathing issues to their healthcare provider.
Portopulmonary Hypertension (High Blood Pressure in Lung Arteries)What Happens? Portopulmonary hypertension emerges when high pressure in the portal system affects the arteries in the lungs. These arteries narrow or tighten, forcing the heart to work harder to move blood through them [4]. Over time, this strain can lead to heart and lung challenges.
Symptoms
Treatment
Because this complication involves both the liver and the lungs, specialists typically coordinate care—often including a gastroenterologist, a hepatologist, and a pulmonologist.
Hepatorenal Syndrome (Kidney Failure Due to Liver Disease)What Happens? With severe liver damage, overall circulation is disrupted. As a result, not enough blood reaches the kidneys, leading them to fail. This condition is called hepatorenal syndrome (HRS) [3]. It can develop quickly and is a serious concern for those with advanced cirrhosis.
The splenic vein, which drains blood from the spleen into the portal vein, plays a significant role in contributing to elevated portal venous pressure. Increased blood flow or obstruction in the splenic vein can lead to complications such as portal hypertension.
Symptoms
Treatment
Hepatorenal syndrome usually signals an urgent state of liver disease. Monitoring kidney function through regular tests can help catch early warning signs and begin treatments sooner.
Final ThoughtsPortal hypertension is far more than just high pressure in a single vein. Its far-reaching effects can strain multiple organs and systems throughout the body. Varices in the esophagus and stomach may burst, causing life-threatening bleeding. If portal hypertension compromises blood flow to the kidneys, hepatorenal syndrome can result in kidney failure.
Portal hypertension, often complicated by inferior vena cava obstruction, can be managed through medication, procedures like endoscopic band ligation or TIPS, and in severe cases, liver transplantation. Recognizing warning signs like sudden weight gain, confusion, difficulty breathing, or unusual bleeding allows for quicker intervention and better outcomes. Routine checkups and tests are vital for early detection and effective management, enabling many patients to live fuller, healthier lives.
References[1] Simonetto, D. A., Liu, M., & Kamath, P. S. (2019). Portal Hypertension and Related Complications: Diagnosis and Management. Mayo Clinic proceedings, 94(4), 714–726. Https://doi.Org/10.1016/j.Mayocp.2018.12.020
[2] Bosch, J., & García-Pagán, J. C. (2000). Complications of cirrhosis. I. Portal hypertension. Journal of hepatology, 32(1 Suppl), 141–156. Https://doi.Org/10.1016/s0168-8278(00)80422-5
[3] Garcia-Tsao G. (2005). Portal hypertension. Current opinion in gastroenterology, 21(3), 313–322. Https://doi.Org/10.1097/01.Mog.0000158110.13722.E0
[4] Bommena, S., & Fallon, M. B. (2024). Pulmonary Complications of Portal Hypertension. Clinics in liver disease, 28(3), 467–482. Https://doi.Org/10.1016/j.Cld.2024.03.005
Managing Pulmonary Hypertension In Pregnancy
Pulmonary arterial hypertension (PAH) can be a challenging complication to manage during pregnancy; women with PAH who are pregnant are considered a high-risk population, and they face higher rates of maternal and fetal complications.
Close monitoring and individualizing treatment plans should be top priorities for the multidisciplinary teams caring for women who are pregnant or are considering pregnancy and exhibiting signs of pulmonary hypertension, according to new research published in International Journal of Cardiology Congenital Heart Disease.1
This patient population is known to have higher risks of maternal morbidity and mortality, in addition to poor fetal outcomes, and newer data indicate that individual prognosis may be dependent on underlying etiology, such as hemodynamic changes—or alterations in blood flow such as from a cardiovascular condition.2
For this analysis, the investigators used these disease classifications of pulmonary hypertension:
Pulmonary hypertension typically is diagnosed when someone exhibits a mean pulmonary arterial pressure (mPAP) above 20 mm Hg at rest, but global guidance on risk stratification does not include much information on pregnancy-related outcomes. Also, women with pulmonary arterial hypertension (PAH) are classified as World Health Organization class IV, a group that has the highest risk of complications and an estimated maternal cardiac event rate of 40% to 100%.
In pregnant women, in particular, who have PAH, prominent cardiac complications include cardiac arrest, pulmonary hypertensive crisis, intrauterine growth restriction, and miscarriage. Those with severe or idiopathic PAH are at the highest risk during pregnancy, according to data from the Registry of Pregnancy And Cardiac disease.
Women with pulmonary arterial hypertension who are pregnant or considering pregnancy are considered a high-risk population, and they face increased rates of maternal and fetal complications.Image Credit: ©Mediteraneo-stock.Adobe.Com
Priorities Prior to PregnancyAmong women with heart/cardiovascular disease who have PAH, the study authors recommend having pregnancy—even fertility—discussions soon after a diagnosis, so that safer contraception can be considered, such as that which contains progesterone instead of estrogen. Orally administered estrogen has been implicated in influencing the risk of high blood pressure.3 They also recommend counseling on 2 fronts: to address maternal and fetal risks, such as adjusting any current medications to avoid upping teratogenic-related complications, and to discuss genetic counseling for patients who have hereditary disease.
Priorities During PregnancyThe authors recommend a full clinical workup with the patient's multidisciplinary team, and this should encompass a comprehensive risk assessment, discussions on termination for patients facing an especially high risk, and recommendations for future contraception. Careful monitoring for potential anemia, infection, and arrhythmia is also necessary, and the patient's team should schedule regular evaluations of oxygen saturation and B-type natriuretic peptide, in addition to echocardiographies. Again, teratogenic risk from PAH medications needs to be investigated.
Priorities After PregnancyThe delivery method should be individualized by patient risk. Cesarean section is safer for women who have severe PAH, and vaginal delivery is appropriate for women who have mild PAH. Delivery in a tertiary care facility is advised in either case. Pain relief is a prominent concern, and for this, fluids should be continuously monitored. When spinal block becomes necessary, hemodynamic changes require constant monitoring. After delivery, the study authors noted again the importance of observing fluid levels, intervening with anticoagulation as needed, and follow-up.
"The outcome of pregnancy for some forms of PH is good while in others, including severe PAH, idiopathic PAH, [and] other forms of PAH, the outcomes are poor," the authors wrote. "Women considering pregnancy need to be counselled regarding the risks as although these have decreased significantly in the last 2 decades with better monitoring and targeted PAH therapy, pregnancy is still associated with a mortality rate of around 15% to 25% in some forms of PH."
References
1. Wander G, Montanaro C, Dixit P, Dob D, Johnson MR, Patel RR. Pregnancy and pulmonary artery hypertension: management challenges. Int J Cardiol Congenit Heart Dis. 2025:19:100566. Doi:10.1016/j.Ijcchd.2025.100566
2. Hemodynamics. Cleveland Clinic. Accessed March 18, 2025. Https://my.Clevelandclinic.Org/health/body/24013-hemodynamics
3. Women taking oral estrogen hormones may have increased risk of high blood pressure. News release. American Heart Association; June 5, 2023. Accessed March 18, 2025. Https://newsroom.Heart.Org/news/women-taking-oral-estrogen-hormones-may-have-increased-risk-of-high-blood-pressure
Merck's Winrevair: Pulmonary Arterial Hypertension Drug Shows Success Ahead Of Schedule
The Latest
Merck has announced the early termination of its Phase 3 HYPERION clinical trial for Winrevair following highly promising results that met efficacy endpoints ahead of schedule. Winrevair, a new drug candidate for the treatment of pulmonary arterial hypertension (PAH), has shown significant improvements in key health markers. The decision to halt the study early was based on an earlier phase 3 ZENITH trial that had strong efficacy results for which an independent data monitoring committee had urged Merck to stop the trial early and offer Winrevair to all patients in the study. In the ZENITH trial, the primary outcome measure was time to clinical worsening as measured by first confirmed morbidity or mortality event and secondary outcomes measured improvement in six-minute walk distance, a widely used measure of exercise capacity in PAH patients. The results significantly exceeded expectations, reinforcing the drug's potential to improve quality of life and mobility for patients with this condition.
Physician's Perspective
PAH is a rare but severe cardiovascular disorder characterized by increased blood pressure in the lungs due to narrowing of pulmonary arteries. Over time, the condition results in right heart failure and significantly reduces life expectancy. The five-year mortality rate for patients with PAH is approximately 43%. Common symptoms include shortness of breath, dizziness, and fatigue, all of which progressively worsen without effective intervention. Current treatments focus on symptom management, but many patients still experience declining function over time. Winrevair presents a breakthrough in PAH management by targeting key molecular pathways that regulate blood vessel remodeling and pulmonary artery narrowing. Physicians have responded positively to the trial results, emphasizing the potential of Winrevair to not only improve symptoms but also modify disease progression in PAH patients. If approved, it would provide a much-needed alternative for patients with limited treatment options.
Molecular Target of Therapy
Winrevair is an activin-signaling inhibitor. This is a key signaling pathway involved in the growth and remodeling of blood vessels. Derangements in this pathway are implicated in PAH. By blocking this signaling pathway, Winrevair promotes dilation of blood vessels, leading to a reduction in pulmonary artery pressures.
Company History
Merck, a global pharmaceutical leader, has a long-standing commitment to developing innovative therapies across various therapeutic areas. The company has made significant strides in cardiovascular and pulmonary medicine, with a strong focus on unmet medical needs. Winrevair is was developed through Merck's extensive research and development efforts, aimed at addressing the complex nature of PAH. Merck continues to lead in the oncology market with Keytruda and has a strong presence in the vaccine therapeutic area with Gardasil.
Additional Reading: https://pubmed.Ncbi.Nlm.Nih.Gov/36877098/
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