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Abstract
PURPOSE OF REVIEW To understand the rational of establishing a goal-oriented therapy for pulmonary arterial hypertension management. RECENT FINDINGS During the last decades, the development of targeted therapies and the recognition of prognostic markers represented a major step for improving pulmonary arterial hypertension survival. Now, changing the strategy on using these compounds therapies might represent the best way to optimize treatment response. SUMMARY Prespecified goals with regular reassessment should be incorporated as the routine practice for pulmonary arterial hypertension management to provide the best available treatment, aiming to improve or maintain every patient in a clinical and functional status that reflects better long-term survival.
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Nathan SD, King CS. Treatment of pulmonary hypertension in idiopathic pulmonary fibrosis: shortfall in efficacy or trial design? DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:875-85. [PMID: 25061279 PMCID: PMC4085308 DOI: 10.2147/dddt.s64907] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a disease that carries a high mortality. Pulmonary hypertension (PH) frequently complicates the course of patients with IPF and is associated with significantly worse outcomes. Whether PH is a surrogate or driver of these worse outcomes remains unanswered, but the presence of PH represents an attractive target for therapy. This review delves into the various pulmonary vasoactive agents that have been subjected to study in IPF, the pitfalls of some of these prior studies, and attempts to lay a foundation for future study designs targeting PH in IPF.
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Affiliation(s)
- Steven D Nathan
- Advanced Lung Disease Clinic, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Christopher S King
- Advanced Lung Disease Clinic, Inova Fairfax Hospital, Falls Church, VA, USA
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Matura LA, McDonough A, Hanlon AL, Carroll DL. Development and initial psychometric properties of the Pulmonary Arterial Hypertension Symptom Scale (PAHSS). Appl Nurs Res 2014; 28:42-7. [PMID: 24880966 DOI: 10.1016/j.apnr.2014.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/23/2014] [Accepted: 04/05/2014] [Indexed: 11/28/2022]
Abstract
AIMS The aim of this study is to report the development and psychometric properties of the Pulmonary Arterial Hypertension Symptom Scale (PAHSS). BACKGROUND Patients with pulmonary arterial hypertension (PAH) experience multiple symptoms such as dyspnea, fatigue and chest pain, yet there is no comprehensive, validated symptom assessment tool to date. METHODS This study used a cross sectional design. Participants completed: socio-demographic and medical data form, the PAHSS, the Medical Outcomes Study Short Form-36 and the Profile of Mood States short form. RESULTS The PAHSS contains 17 symptoms measured on a 0 to 10 scale. Principal components analysis demonstrated a three factor solution for the PAHSS: pulmonary, diffuse, and cardiac. Coefficient alphas were good. Statistically significant Pearson coefficients were found between the PAHSS and the Medical Outcomes Study Short Form-36 and the Profile of Mood States short form. CONCLUSION Findings show that the PAHSS is a promising scale to assess symptom severity.
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Affiliation(s)
- Lea Ann Matura
- University of Pennsylvania, School of Nursing, Philadelphia, PA 19104-4217 USA.
| | | | - Alexandra L Hanlon
- University of Pennsylvania, School of Nursing, Philadelphia, PA 19104-4217 USA.
| | - Diane L Carroll
- Munn Center for Nursing Research, Institute for Patient Care, Boston, MA 02114 USA.
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Adachi S, Hirashiki A, Nakano Y, Shimazu S, Murohara T, Kondo T. Prognostic factors in pulmonary arterial hypertension with Dana Point group 1. Life Sci 2014; 118:404-9. [PMID: 24632476 DOI: 10.1016/j.lfs.2014.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/18/2014] [Accepted: 03/01/2014] [Indexed: 02/04/2023]
Abstract
AIMS To clarify the prognosis and prognostic factors in pulmonary arterial hypertension (PAH) patients in real-world medical practice in the Tokai area in Japan. MAIN METHODS We conducted a retrospective, multicenter observational study. The data of 81 patients diagnosed with Dana Point group 1 or 1' PAH was collected from January 2005 to January 2013. The primary outcome was all-cause death. KEY FINDINGS The patients consisted of 34 cases of idiopathic PAH (IPAH), 28 of connective tissue-associated PAH (CTD-PAH), 16 of congenital heart disease-associated PAH (CHD-PAH) and others. Mean age was 51 years and mean observation period was 46 months. The systolic blood pressure (BPs) was 117±23 mm Hg. Pericardial effusion was observed in 27.0% of patients. The mean right atrial pressure (mRAP) was 10.2±7.3 mm Hg. In the univariate Cox regression analysis, WHO-FCS III & IV, a cardiac index (CI)<2.5 L/min/m(2), and the presence of pericardial effusion at baseline were significantly associated with all-cause death. In the multivariate analysis, the pericardial effusion (HR 3.3, 95% CI 1.03-10.63, p=0.04) and mRAP (HR 3.2, 95% CI 1.03-9.83, p=0.04) or CI<2.5 L/min/m(2) (HR 3.89, 95% CI 1.05-14.45, p=0.04) were the independent predictors of mortality. SIGNIFICANCE The presence of pericardial effusion and mRAP or CI<2.5 L/min/m(2) at diagnosis indicated high mortality.
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Affiliation(s)
- Shiro Adachi
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Akihiro Hirashiki
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Shuzo Shimazu
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan.
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Abstract
With significant therapeutic advances in the field of pulmonary arterial hypertension, the need to identify clinically relevant treatment goals that correlate with long-term outcome has emerged as 1 of the most critical tasks. Current goals include achieving modified New York Heart Association functional class I or II, 6-min walk distance >380 m, normalization of right ventricular size and function on echocardiograph, a decreasing or normalization of B-type natriuretic peptide (BNP), and hemodynamics with right atrial pressure <8 mm Hg and cardiac index >2.5 mg/kg/min(2). However, to more effectively prognosticate in the current era of complex treatments, it is becoming clear that the "bar" needs to be set higher, with more robust and clearer delineations aimed at parameters that correlate with long-term outcome; namely, exercise capacity and right heart function. Specifically, tests that accurately and noninvasively determine right ventricular function, such as cardiac magnetic resonance imaging and BNP/N-terminal pro-B-type natriuretic peptide, are emerging as promising indicators to serve as baseline predictors and treatment targets. Furthermore, studies focusing on outcomes have shown that no single test can reliably serve as a long-term prognostic marker and that composite treatment goals are more predictive of long-term outcome. It has been proposed that treatment goals be revised to include the following: modified New York Heart Association functional class I or II, 6-min walk distance ≥ 380 to 440 m, cardiopulmonary exercise test-measured peak oxygen consumption >15 ml/min/kg and ventilatory equivalent for carbon dioxide <45 l/min/l/min, BNP level toward "normal," echocardiograph and/or cardiac magnetic resonance imaging demonstrating normal/near-normal right ventricular size and function, and hemodynamics showing normalization of right ventricular function with right atrial pressure <8 mm Hg and cardiac index >2.5 to 3.0 l/min/m(2).
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Barst RJ, Chung L, Zamanian RT, Turner M, McGoon MD. Functional Class Improvement and 3-Year Survival Outcomes in Patients With Pulmonary Arterial Hypertension in the REVEAL Registry. Chest 2013; 144:160-168. [DOI: 10.1378/chest.12-2417] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Ngian GS, Stevens W, Prior D, Gabbay E, Roddy J, Tran A, Minson R, Hill C, Chow K, Sahhar J, Proudman S, Nikpour M. Predictors of mortality in connective tissue disease-associated pulmonary arterial hypertension: a cohort study. Arthritis Res Ther 2012; 14:R213. [PMID: 23039366 PMCID: PMC3580525 DOI: 10.1186/ar4051] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 10/05/2012] [Indexed: 01/14/2023] Open
Abstract
Introduction Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). We sought to quantify survival and determine factors predictive of mortality in a cohort of patients with CTD-associated PAH (CTD-PAH) in the current era of advanced PAH therapy. Methods Patients with right heart catheter proven CTD-PAH were recruited from six specialised PAH treatment centres across Australia and followed prospectively. Using survival methods including Cox proportional hazards regression, we modelled for all-cause mortality. Independent variables included demographic, clinical and hemodynamic data. Results Among 117 patients (104 (94.9%) with systemic sclerosis), during 2.6 ± 1.8 (mean ± SD) years of follow-up from PAH diagnosis, there were 32 (27.4%) deaths. One-, two- and three-year survivals were 94%, 89% and 73%, respectively. In multiple regression analysis, higher mean right atrial pressure (mRAP) at diagnosis (hazard ratio (HR) = 1.13, 95% CI: 1.04 to 1.24, P = 0.007), lower baseline six-minute walk distance (HR = 0.64, 95% CI: 0.43 to 0.97, P = 0.04), higher baseline World Health Organization functional class (HR = 3.42, 95% CI: 1.25 to 9.36, P = 0.04) and presence of a pericardial effusion (HR = 3.39, 95% CI: 1.07 to 10.68, P = 0.04) were predictive of mortality. Warfarin (HR = 0.20, 95% CI: 0.05 to 0.78, P = 0.02) and combination PAH therapy (HR = 0.20, 95% CI: 0.05 to 0.83, P = 0.03) were protective. Conclusions In this cohort of CTD-PAH patients, three-year survival was 73%. Independent therapeutic predictors of survival included warfarin and combination PAH therapy. Our findings suggest that anticoagulation and combination PAH therapy may improve survival in CTD-PAH. This observation merits further evaluation in randomised controlled trials.
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Barrier M, Meloche J, Jacob MH, Courboulin A, Provencher S, Bonnet S. Today's and tomorrow's imaging and circulating biomarkers for pulmonary arterial hypertension. Cell Mol Life Sci 2012; 69:2805-31. [PMID: 22446747 PMCID: PMC11115077 DOI: 10.1007/s00018-012-0950-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 02/18/2012] [Accepted: 02/20/2012] [Indexed: 01/04/2023]
Abstract
The pathobiology of pulmonary arterial hypertension (PAH) involves a remodeling process in distal pulmonary arteries, as well as vasoconstriction and in situ thrombosis, leading to an increase in pulmonary vascular resistance, right heart failure and death. Its etiology may be idiopathic, but PAH is also frequently associated with underlying conditions such as connective tissue diseases. During the past decade, more than welcome novel therapies have been developed and are in development, including those increasingly targeting the remodeling process. These therapeutic options modestly increase the patients' long-term survival, now approaching 60% at 5 years. However, non-invasive tools for confirming PAH diagnosis, and assessing disease severity and response to therapy, are tragically lacking and would help to select the best treatment. After exclusion of other causes of pulmonary hypertension, a final diagnosis still relies on right heart catheterization, an invasive technique which cannot be repeated as often as an optimal follow-up might require. Similarly, other techniques and biomarkers used for assessing disease severity and response to treatment generally lack specificity and have significant limitations. In this review, imaging as well as current and future circulating biomarkers for diagnosis, prognosis, and follow-up are discussed.
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Affiliation(s)
- Marjorie Barrier
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Jolyane Meloche
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Maria Helena Jacob
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Audrey Courboulin
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Ste-Foy, Québec, QC G1V 4G5 Canada
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Frantz RP, McGoon MD. Diagnostic dilemmas in pulmonary hypertension. Heart Fail Clin 2012; 8:331-52. [PMID: 22748898 DOI: 10.1016/j.hfc.2012.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Dilemmas persist in the screening, assessment, and follow-up of patients with pulmonary hypertension, relating to issues of whom and how to screen, how to resolve ambiguities in the clinical classification of patients with multiple potential substrates of pulmonary vascular disease, how to interpret test results, how to integrate multiple clinical parameters into a global diagnosis, how to use ambiguous test results, how to determine disease severity and prognosis, and how to monitor patients on treatment. This article describes how to incorporate available information into the diagnostic process, and where lack of concrete data should impose caution in patient management.
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Affiliation(s)
- Robert P Frantz
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Arena R, Guazzi M, Myers J, Grinnen D, Forman DE, Lavie CJ. Cardiopulmonary exercise testing in the assessment of pulmonary hypertension. Expert Rev Respir Med 2011; 5:281-93. [PMID: 21510737 DOI: 10.1586/ers.11.4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The assessment of patients with suspected or confirmed pulmonary arterial hypertension (PAH) and secondary pulmonary hypertension (PH) continues to evolve and, in recent years, evidence demonstrating that cardiopulmonary exercise testing (CPX) provides valuable information has grown at an impressive rate. The key premise supporting the use of CPX is that certain variables obtained provide insight into the degree of ventilation/perfusion mismatching secondary to altered pulmonary hemodynamics. In this article, we discuss the pathophysiology of PAH and secondary PH and its impact on cardiac function, review the clinical presentation of patients with elevated pulmonary pressures and outline a case for the use of CPX as an integral assessment technique, discuss CPX technology and testing procedures, and review the current state of available evidence and provide clinical recommendations for CPX in the setting of known or suspected PAH and secondary PH.
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Affiliation(s)
- Ross Arena
- Virginia Commonwealth University, Richmond, VA, USA.
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61
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Cornwell WK, McLaughlin VV, Krishnan SM, Rubenfire M. Does the outcome justify an oral-first treatment strategy for management of pulmonary arterial hypertension? Chest 2011; 140:697-705. [PMID: 21622545 DOI: 10.1378/chest.10-3019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Guidelines for the treatment of World Health Organization (WHO) functional class (FC) III pulmonary arterial hypertension (PAH) provide for oral (PO) therapy or parenteral prostacyclins at the discretion of expert physicians. The objective of this study was to assess the appropriateness of PO-first treatment in patients with WHO FC III PAH. METHODS This study was a retrospective analysis of 79 treatment-naive adult patients with idiopathic, familial, or anorexigen-associated PAH, referred to a single pulmonary hypertension center. Forty-eight received either PO therapy with an endothelin receptor antagonist, calcium channel blocker, or phosphodiesterase inhibitor (PO group) and 31 an IV or subcutaneous (SC) prostacyclin (IV/SC group). RESULTS Patients in the IV/SC group had a significantly worse baseline hemodynamic profile; however, on univariate analysis, there was no association between hemodynamics and mortality. Initial treatment with PO vs IV/SC therapy was associated with a lower overall mortality (20.8% vs 45.2%, P = .02) and a lower 5-year mortality (14.6% vs 32.3%, P = .062). Based on the National Institutes of Health equation, actual survival for patients who received PO therapy was greater than predicted at 5 years. Finally, there were similar improvements between groups in 6-min walk distance (P = .38) at 6 to 12 months after initiation of treatment. CONCLUSIONS For WHO FC III PAH that is idiopathic, familial, or anorexigen associated, the clinical decision for treatment with a PO-first strategy is associated with a high survival rate when patients are appropriately risk stratified prior to initiation of therapy. The more potent prostacyclins can be reserved for high-risk patients, those with evidence of disease progression, or those with treatment failure.
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Affiliation(s)
- William K Cornwell
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sangeetha M Krishnan
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Melvyn Rubenfire
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI.
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Ghofrani HA, Voswinckel R, Gall H, Schermuly R, Weissmann N, Seeger W, Grimminger F. Riociguat for pulmonary hypertension. Future Cardiol 2010; 6:155-66. [DOI: 10.2217/fca.10.5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pulmonary hypertension (PH) encompasses a group of diseases associated with progressively increasing pulmonary vascular resistance, right heart failure and premature death. Riociguat is a novel, first-in-class oral drug that directly stimulates soluble guanylate cyclase, both independently of the endogenous vasodilator nitric oxide (NO) and in synergy with NO. Single oral doses of riociguat were well tolerated in a Phase I study of healthy volunteers. They had a favorable safety profile, and improved pulmonary hemodynamics and cardiac index to a greater extent than inhaled NO in a proof-of-concept study in patients with moderate-to-severe PH. In a 12-week Phase II trial in patients with chronic thromboembolic PH or pulmonary arterial hypertension, pulmonary hemodynamics and exercise capacity improved following individual dose titration with oral riociguat, which was generally well tolerated. Further trials in PH have been initiated.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
| | - Robert Voswinckel
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
| | - Ralph Schermuly
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
| | - Norbert Weissmann
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
| | - Friedrich Grimminger
- Department of Internal Medicine, Medical Clinic II/V, University Hospital Giessen and Marburg GmbH, Klinikstrasse 36, 35392 Giessen, Germany
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Arena R, Lavie CJ. Cardiopulmonary stress testing in patients with pulmonary artery hypertension. Mayo Clin Proc 2009; 84:939; author reply 940. [PMID: 19797782 PMCID: PMC2755813 DOI: 10.1016/s0025-6196(11)60510-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2022]
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Arena R, Lavie CJ. Cardiopulmonary stress testing in patients with pulmonary artery hypertension. Mayo Clin Proc 2009; 84:939; author reply 940. [PMID: 19797782 PMCID: PMC2755813 DOI: 10.4065/84.10.939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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