The most appropriate initial management is treatment of systemic arterial hypertension with lisinopril. This patient has pulmonary hypertension (PH) in the setting of diastolic heart failure (also known as heart failure with preserved ejection fraction [HFpEF]). HFpEF, an increasingly common cause of PH, is often seen in association with systemic hypertension and left ventricular hypertrophy. PH related to left-sided heart disease is classified as group 2, and treatment is directed at the underlying cardiac disease. Therefore, therapy for HFpEF is based on treating the causes and symptoms of the heart failure. Because hypertension is a common cause of HFpEF, aggressive control of the systemic arterial blood pressure is necessary. Because no specific agent has definitively proved to be more effective than another, therapy should follow hypertension treatment guidelines.

Epoprostenol is an advanced therapy; it is an intravenous pulmonary vasodilator reserved for management of group 1 PH (pulmonary arterial hypertension) associated with advanced symptoms and functional limitation.

Right heart catheterization is not an appropriate initial test in the diagnosis or management of patients with PH related to heart failure, although it may be useful later if initial treatments aimed at the underlying condition are not effective in improving symptoms or pulmonary artery pressures.

The pulmonary vasodilator sildenafil is considered advanced therapy, which is directed at PH itself rather than the underlying cause, and is indicated for the treatment of group 1 pulmonary arterial hypertension. Not only is the role of such drugs in the treatment of groups 2 to 5 PH unclear, advanced therapy can alter ventilation-perfusion relationships and be deleterious in these patients.