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Guha S, Harikrishnan S, Ray S, Sethi R, Ramakrishnan S, Banerjee S, Bahl VK, Goswami KC, Banerjee AK, Shanmugasundaram S, Kerkar PG, Seth S, Yadav R, Kapoor A, Mahajan AU, Mohanan PP, Mishra S, Deb PK, Narasimhan C, Pancholia AK, Sinha A, Pradhan A, Alagesan R, Roy A, Vora A, Saxena A, Dasbiswas A, Srinivas BC, Chattopadhyay BP, Singh BP, Balachandar J, Balakrishnan KR, Pinto B, Manjunath CN, Lanjewar CP, Jain D, Sarma D, Paul GJ, Zachariah GA, Chopra HK, Vijayalakshmi IB, Tharakan JA, Dalal JJ, Sawhney JPS, Saha J, Christopher J, Talwar KK, Chandra KS, Venugopal K, Ganguly K, Hiremath MS, Hot M, Das MK, Bardolui N, Deshpande NV, Yadava OP, Bhardwaj P, Vishwakarma P, Rajput RK, Gupta R, Somasundaram S, Routray SN, Iyengar SS, Sanjay G, Tewari S, G S, Kumar S, Mookerjee S, Nair T, Mishra T, Samal UC, Kaul U, Chopra VK, Narain VS, Raj V, Lokhandwala Y. CSI position statement on management of heart failure in India. Indian Heart J 2018; 70 Suppl 1:S1-S72. [PMID: 30122238 PMCID: PMC6097178 DOI: 10.1016/j.ihj.2018.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Santanu Guha
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | - S Harikrishnan
- Chief Coordinator, CSI HF Position Statement; Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, India.
| | - Saumitra Ray
- Convenor, CSI Guidelines Committee; Vivekananda Institute of Medical Sciences, Kolkata
| | - Rishi Sethi
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow
| | - S Ramakrishnan
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Suvro Banerjee
- Joint Convenor, CSI Guidelines Committee; Apollo Hospitals, Kolkata
| | - V K Bahl
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - K C Goswami
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Amal Kumar Banerjee
- Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal, India
| | - S Shanmugasundaram
- Department of Cardiology, Tamil Nadu Medical University, Billroth Hospital, Chennai, Tamil Nadu, India
| | | | - Sandeep Seth
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Yadav
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
| | - Ajaykumar U Mahajan
- Department of Cardiology, LokmanyaTilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - P P Mohanan
- Department of Cardiology, Westfort Hi Tech Hospital, Thrissur, Kerala, India
| | - Sundeep Mishra
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - P K Deb
- Daffodil Hospitals, Kolkata, West Bengal, India
| | - C Narasimhan
- Department of Cardiology & Chief of Electro Physiology Department, Care Hospitals, Hyderabad, Telangana, India
| | - A K Pancholia
- Clinical & Preventive Cardiology, Arihant Hospital & Research Centre, Indore, Madhya Pradesh, India
| | | | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - R Alagesan
- The Tamil Nadu Dr.M.G.R. Medical University, Tamil Nadu, India
| | - Ambuj Roy
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | - Amit Vora
- Arrhythmia Associates, Mumbai, Maharashtra, India
| | - Anita Saxena
- Joint Coordinator, CSI HF Position Statement; All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - B P Singh
- Department of Cardiology, IGIMS, Patna, Bihar, India
| | | | - K R Balakrishnan
- Cardiac Sciences, Fortis Malar Hospital, Adyar, Chennai, Tamil Nadu, India
| | - Brian Pinto
- Holy Family Hospitals, Mumbai, Maharashtra, India
| | - C N Manjunath
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
| | | | - Dharmendra Jain
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Dipak Sarma
- Cardiology & Critical Care, Jorhat Christian Medical Centre Hospital, Jorhat, Assam, India
| | - G Justin Paul
- Department of Cardiology, Madras Medical College, Chennai, Tamil Nadu, India
| | | | | | - I B Vijayalakshmi
- Bengaluru Medical College and Research Institute, Bengaluru, Karnataka, India
| | - J A Tharakan
- Department of Cardiology, P.K. Das Institute of Medical Sciences, Vaniamkulam, Palakkad, Kerala, India
| | - J J Dalal
- Kokilaben Hospital, Mumbai, Maharshtra, India
| | - J P S Sawhney
- Department of Cardiology, Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
| | - Jayanta Saha
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | | | - K K Talwar
- Max Healthcare, Max Super Speciality Hospital, Saket, New Delhi, India
| | - K Sarat Chandra
- Indo-US Super Speciality Hospital & Virinchi Hospital, Hyderabad, Telangana, India
| | - K Venugopal
- Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| | - Kajal Ganguly
- Department of Cardiology, N.R.S. Medical College, Kolkata, West Bengal, India
| | | | - Milind Hot
- Department of CTVS, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mrinal Kanti Das
- B.M. Birla Heart Research Centre & CMRI, Kolkata, West Bengal, India
| | - Neil Bardolui
- Department of Cardiology, Excelcare Hospitals, Guwahati, Assam, India
| | - Niteen V Deshpande
- Cardiac Cath Lab, Spandan Heart Institute and Research Center, Nagpur, Maharashtra, India
| | - O P Yadava
- National Heart Institute, New Delhi, India
| | - Prashant Bhardwaj
- Department of Cardiology, Military Hospital (Cardio Thoracic Centre), Pune, Maharashtra, India
| | - Pravesh Vishwakarma
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow
| | | | - Rakesh Gupta
- JROP Institute of Echocardiography, New Delhi, India
| | | | - S N Routray
- Department of Cardiology, SCB Medical College, Cuttack, Odisha, India
| | - S S Iyengar
- Manipal Hospitals, Bangalore, Karnataka, India
| | - G Sanjay
- Chief Coordinator, CSI HF Position Statement; Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum, Kerala, India
| | - Satyendra Tewari
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
| | | | - Soumitra Kumar
- Convenor, CSI Guidelines Committee; Vivekananda Institute of Medical Sciences, Kolkata
| | - Soura Mookerjee
- Chairman, CSI Guidelines Committee; Medical College Kolkata, India
| | - Tiny Nair
- Department of Cardiology, P.R.S. Hospital, Trivandrum, Kerala, India
| | - Trinath Mishra
- Department of Cardiology, M.K.C.G. Medical College, Behrampur, Odisha, India
| | | | - U Kaul
- Batra Heart Center & Batra Hospital and Medical Research Center, New Delhi, India
| | - V K Chopra
- Heart Failure Programme, Department of Cardiology, Medanta Medicity, Gurugram, Haryana, India
| | - V S Narain
- Joint Coordinator, CSI HF Position Statement; KG Medical University, Lucknow
| | - Vimal Raj
- Narayana Hrudayalaya Hospital, Bangalore, Karnataka, India
| | - Yash Lokhandwala
- Mumbai & Visiting Faculty, Sion Hospital, Mumbai, Maharashtra, India
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Yoshihisa A, Kimishima Y, Kiko T, Sato Y, Watanabe S, Kanno Y, Abe S, Miyata-Tatsumi M, Sato T, Suzuki S, Oikawa M, Kobayashi A, Yamaki T, Sugimoto K, Kunii H, Nakazato K, Suzuki H, Ishida T, Takeishi Y. Liver fibrosis marker, 7S domain of collagen type IV, in patients with pre-capillary pulmonary hypertension. Int J Cardiol 2018; 258:269-274. [DOI: 10.1016/j.ijcard.2018.01.138] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 02/08/2023]
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Luo D, Zhang C, Huang Y, Huang T, Li H. Metabolic Status in Patients with Operable vs. Inoperable Left-to-Right Shunts. Med Sci Monit 2018; 24:2655-2660. [PMID: 29705813 PMCID: PMC5946741 DOI: 10.12659/msm.907090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/25/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Previous studies have shown the prognostic value of insulin resistance, hyperuricemia, and dyslipidemia in clinical outcome of pulmonary arterial hypertension. Whether these metabolic derangements are different between operable and inoperable left-to-right shunts is unknown. MATERIAL AND METHODS Our study included 116 patients with left-to-right shunts (76 with atrial septal defect and 40 with ventricular septal defect) with or without pulmonary arterial hypertension. Operability of defect closure were assessed by cardiac catheterization and patients were subdivided into an operable group or an inoperable group. The metabolic status, including prediabetes, hyperuricemia, dyslipidemia, hypertension and obesity, were compared between groups. RESULTS Patients receiving defect correction had a lower HbA1c (B: 5.52±0.49 vs. 5.71±0.41, p=0.042) and uric acid (C: 358±105 vs. 406±126, p=0.029) but a higher HDLC (D: 1.21±0.33 vs. 1.08±0.22, p=0.017) and BMI (A: 20.4±3.9 vs. 18.8±3.1, p=0.023). Patients in the inoperable group had a higher prevalence of prediabetes (58% vs. 41%, p=0.076), hyperuricemia (37.2% vs. 21.9, p=0.106), dyslipidemia (74% vs. 56%, p=0.049) but a lower prevalence of hypertension (13.9% vs. 30.1%, p=0.049) and obesity (4.6% vs. 12.3%, p=0.301). According to logistic regression, only HbA1c (1.76 (0.53, 2.99), HR (95% CI), p=0.005) remained significant for pulmonary vascular resistance. CONCLUSIONS Although prediabetes, hyperuricemia, and dyslipidemia were all more prevalent in patients with inoperable left-to-right shunts, only prediabetes was found to be significantly associated with higher pulmonary vascular resistance.
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Affiliation(s)
- Dongling Luo
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
- Shantou University Medical College, Guangzhou, Guangdong, P.R. China
| | - Caojin Zhang
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Yigao Huang
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Tao Huang
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
| | - Hezhi Li
- Department of Cardiology, Guangdong Provincial Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, P.R. China
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Desmosine and Isodesmosine as a Novel Biomarker for Pulmonary Arterial Hypertension: A Pilot Study. Am J Ther 2018; 24:e399-e404. [PMID: 26237301 DOI: 10.1097/mjt.0000000000000260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Delayed diagnosis is common in patients with pulmonary arterial hypertension (PAH). Right-sided heart catheterization, the gold standard for diagnosis, is invasive and cannot be applied for routine screening. Some biomarkers have been looked into; however, due to the lack of a clear pathological mechanism linking the marker to PAH, the search for an ideal one is still ongoing. Elastin is a significant structural constituent of blood vessels. Its synthesis involves cross-linking of monomers by 2 amino acids, desmosine and isodesmosine (D&I). Being extremely stable, elastin undergoes little metabolic turnover in healthy individuals resulting in very low levels of D&I amino acids in the human plasma, urine, or sputum. We hypothesized that in PAH patients, the elastin turnover is high; which in turn should result in elevated levels of D&I in plasma and urine. Using mass spectrometry, plasma and urine levels of D&I were measured in 20 consecutive patients with PAH confirmed by cardiac catheterization. The levels were compared with 13 healthy controls. The mean level of total plasma D&I in patients with PAH was 0.47 ng/mL and in controls was 0.19 ng/mL (P = 0.001). The mean levels of total D&I in the urine of PAH patients was 20.55 mg/g creatinine and in controls was 12.78 mg/g creatinine (P = 0.005). The mean level of free D&I in the urine of PAH patients was 10.34 mg/g creatinine and in controls was 2.52 mg/g creatinine (P < 0.001). This is the first study highlighting that the serum and urine D&I has a potential to be a novel screening biomarker for patients with PAH. It paves the way for larger studies to analyze its role in assessing for disease severity and response to treatment.
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Reis A, Santos M, Vicente M, Furtado I, Cruz C, Melo A, Carvalho L, Gonçalves F, Sa-Couto P, Almeida L. Health-Related Quality of Life in Pulmonary Hypertension and Its Clinical Correlates: A Cross-Sectional Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3924517. [PMID: 29750153 PMCID: PMC5884279 DOI: 10.1155/2018/3924517] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/18/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) impairment is common in pulmonary hypertension (PH), but its clinical predictors are not well established. This study aims to characterize the HRQoL of patients with pulmonary arterial hypertension (PAH) and other precapillary forms of PH (pcPH) and to explore its clinical correlates. MATERIALS AND METHODS A cross-sectional, observational study of patients with documented PAH and other forms of pcPH. Patients completed two patient-reported outcome measures (PROM): Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) and Nottingham Health Profile (NHP). Clinical characteristics were retrieved from electronic medical records. RESULTS Mean CAMPHOR and NHP scores for the study population were indicative of a moderate HRQoL impairment. Patients in World Health Organisation Functional Classes (WHO FC) III/IV showed significantly worse HRQoL. The main clinical correlates of HRQoL were WHO FC, 6-minute walking distance (6MWD), and Borg dyspnoea index. Overall quality of life (QoL), assessed through CAMPHOR's QoL domain, showed patterns comparable to HRQoL measured by both instruments. CONCLUSIONS HRQoL, measured by two different PROMs, is impaired in Portuguese patients with PAH and other forms of pcPH, particularly in patients with increased disease severity. WHO FC, 6MWD, and Borg dyspnoea index are highly correlated with HRQoL and QoL.
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Affiliation(s)
- Abílio Reis
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Mário Santos
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
- Cardiology Service, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of Porto, Porto, Portugal
| | - Margarida Vicente
- Department of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Inês Furtado
- Internal Medicine Service, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Célia Cruz
- Internal Medicine Service, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Alzira Melo
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Luísa Carvalho
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
- Internal Medicine Service, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Fabienne Gonçalves
- Pulmonary Vascular Disease Unit, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
- Internal Medicine Service, Medicine Department, Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
| | - Pedro Sa-Couto
- Center for Research and Development in Mathematics and Applications, Department of Mathematics, University of Aveiro, Aveiro, Portugal
| | - Luís Almeida
- MedInUP, Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
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Li W, Xiong CM, Gu Q, Wang XT, Cheng XL, Huang L, Yang T, Luo Q, Zhao ZH, Ni XH, Liu ZH, He JG. The clinical characteristics and long-term prognosis of pulmonary arterial hypertension associated with hereditary hemorrhagic telangiectasia. Pulm Circ 2018; 8:2045894018759918. [PMID: 29480092 PMCID: PMC5888830 DOI: 10.1177/2045894018759918] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe complication of hereditary hemorrhagic telangiectasia (HHT); however, little is known about its clinical characteristics and prognosis. Nine newly diagnosed HHT-PAH patients were prospectively recruited between October 2007 and January 2016 and were followed up every half-year. Eighteen idiopathic pulmonary arterial hypertension (IPAH) patients, matched with HHT-PAH patients on mean pulmonary arterial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, cardiac index, and World Health Organization (WHO) functional class (FC), were recruited. The clinical characteristics of HHT-PAH patients were described and the prognosis of these two cohorts were compared. Of HHT-PAH patients, 55.56% were WHO FC III. Kaplan–Meier survival analysis showed one- and three-year survival rates of HHT-PAH patients were 77.8% and 53.3% respectively, which were worse than matched IPAH patients (log rank: P = 0.047). HHT-PAH patients had higher red cell distribution width (14.88 ± 2.93% versus 13.19 ± 0.83%, P = 0.031), larger right ventricular anteroposterior diameter (34.67 ± 6.67 mm versus 28.56 ± 6.35 mm, P = 0.029), and lower mean corpuscular hemoglobin concentration (317.38 ± 17.71 g/L versus 335.72 ± 14.68 g/L, P = 0.011) than matched IPAH patients. Multivariate Cox proportional hazards regression analyses showed baseline total bilirubin independently predicted the mortality of HHT-PAH after adjusting by age, cardiac index, mixed venous oxygen saturation, or serum uric acid. HHT-PAH patients may have a worse prognosis than matched IPAH patients. Baseline total bilirubin may be a promising predictor for the long-term prognosis in HHT-PAH patients.
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Affiliation(s)
- Wen Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Gu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Tong Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Ling Cheng
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Huang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin Luo
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Hai Ni
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Guo He
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Benza RL, Lohmueller LC, Kraisangka J, Kanwar M. Risk Assessment in Pulmonary Arterial Hypertension Patients: The Long and Short of it. ACTA ACUST UNITED AC 2018. [DOI: 10.21693/1933-088x-16.3.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a chronic and rapidly progressive disease that is characterized by extensive narrowing of the pulmonary vasculature, leading to increases in pulmonary vascular resistance, subsequent right ventricular dysfunction, and eventual death. There are currently multiple approved drugs—developed as single or combination therapies in the last few years—that have improved outcome and functionality in PAH. However, despite improvement in short-term survival with these new effective therapies, PAH remains an incurable disease with a median survival of 7 years (Figure 1).1 This chronic disease state may be characterized by morbid events such as hospitalizations that herald rapid disease progression and account for a significant disease burden (Figure 2).23 Physician ability to predict PAH disease progression is critical for determining optimal care of patients. Accurate risk assessment allows clinicians to determine the patient's prognosis, identify treatment goals, and monitor disease progression and the patient's response to treatment. Risk assessment for PAH patients should include a range of clinical, hemodynamic, and exercise parameters, performed in a serial fashion over the treatment course. Patient risk stratification can also help physicians better allocate treatment resources in settings where they are scarce. If widely adopted, risk prediction can enhance the consistency of treatment approaches across PAH practitioners and improve the timeliness of referral for lung transplantation. Hence, along with advancing PAH treatment options, comprehensive risk prediction is essential to make individualized treatment decisions in the current treatment era.
Several tools are currently available for assessing risk in PAH (Figure 3). These include the 2015 European Society of Cardiology/European Respiratory Society pulmonary hypertension guidelines' risk variables,4 the French registry equation,5 the National Institutes of Health risk equation,6 or a risk score such as the one derived from the Registry to Evaluate Early And Long-term PAH Disease Management.1 These registries and evaluations of clinical trial sets have provided important insights into the importance of both modifiable (eg, 6-minute walk distance, functional class, brain natriuretic peptide, and nonmodifiable (eg, age, gender, PAH etiology) risk factors that predict survival. The following review explores commonly cited risk factors, both modifiable and nonmodifiable, and their implications for patient outcomes.
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Maron BA, Abman SH. Translational Advances in the Field of Pulmonary Hypertension. Focusing on Developmental Origins and Disease Inception for the Prevention of Pulmonary Hypertension. Am J Respir Crit Care Med 2017; 195:292-301. [PMID: 27854133 DOI: 10.1164/rccm.201604-0882pp] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Bradley A Maron
- 1 Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,2 Department of Cardiology, Boston VA Healthcare System, Boston, Massachusetts; and
| | - Steven H Abman
- 3 Section of Pulmonary Medicine and.,4 Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Denver Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
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Leberkühne LJ, Ploegstra MJ, Douwes JM, Bartelds B, Roofthooft MTR, Hillege HL, Berger RMF. Serially Measured Uric Acid Levels Predict Disease Severity and Outcome in Pediatric Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2017; 195:401-404. [PMID: 28145758 DOI: 10.1164/rccm.201606-1152le] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Lynn J Leberkühne
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
| | - Mark-Jan Ploegstra
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
| | - Johannes M Douwes
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
| | - Beatrijs Bartelds
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
| | - Marcus T R Roofthooft
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
| | - Hans L Hillege
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
| | - Rolf M F Berger
- 1 University Medical Center Groningen, University of Groningen Groningen, the Netherlands
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Monneret D, Cracowski JL. Comment on direct bilirubin as predictor of severity and mortality in idiopathic pulmonary arterial hypertension. Int J Cardiol 2017; 239:35. [PMID: 28560980 DOI: 10.1016/j.ijcard.2017.04.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/20/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Denis Monneret
- Department of Metabolic Biochemistry, La Pitié Salpêtrière-Charles Foix University Hospital (AP-HP), Paris, France.
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Chon MK, Cho KI, Cha KS, Seo JS, Kim DS. Effects of long-term iloprost treatment on right ventricular function in patients with Eisenmenger syndrome. J Cardiol 2017; 69:741-746. [DOI: 10.1016/j.jjcc.2016.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/29/2016] [Accepted: 07/08/2016] [Indexed: 02/08/2023]
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Lee HW, Choi SM, Lee J, Park YS, Lee CH, Yim JJ, Yoo CG, Kim YW, Han SK, Lee SM. Serum Uric Acid Level as a Prognostic Marker in Patients With Acute Respiratory Distress Syndrome. J Intensive Care Med 2017; 34:404-410. [PMID: 28351229 DOI: 10.1177/0885066617698911] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE: Uric acid acts as both a pathogenic inflammatory mediator and an antioxidative agent. Several studies have shown that uric acid level correlates with the incidence, severity, and prognosis of pulmonary diseases. However, the association between uric acid level and acute respiratory distress syndrome (ARDS) has not been studied. This study was conducted to elucidate how serum uric acid level is related with clinical prognosis of ARDS. METHODS: A retrospective cohort study with propensity score matching was conducted at a medical intensive care unit of a tertiary teaching hospital. The medical records of patients diagnosed with ARDS admitted from 2005 through 2011 were reviewed. RESULTS: Two hundred thirty-seven patients with ARDS met the inclusion criteria. Patients with a serum uric acid level <3.0 mg/dL were classified into the low uric acid group, and those with a level ≥3 mg/dL were classified into the normal to high uric acid group. We selected 40 patients in each group using propensity score matching. A higher percentage of patients in the low uric acid group experienced clinical improvement in ARDS. More patients died from sepsis in the normal to high uric acid group. Kaplan-Meier analysis showed that a low serum uric acid level was significantly associated with better survival rate. CONCLUSION: In patients with ARDS, a low serum uric acid level may be a prognostic marker of a low risk of in-hospital mortality.
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Affiliation(s)
- Hyun Woo Lee
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sun Mi Choi
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jinwoo Lee
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Sik Park
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chang-Hoon Lee
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae-Joon Yim
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chul-Gyu Yoo
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Whan Kim
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung Koo Han
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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63
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Nickel NP, O'Leary JM, Brittain EL, Fessel JP, Zamanian RT, West JD, Austin ED. Kidney dysfunction in patients with pulmonary arterial hypertension. Pulm Circ 2017; 7:38-54. [PMID: 28680564 PMCID: PMC5448543 DOI: 10.1086/690018] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 10/26/2016] [Indexed: 12/19/2022] Open
Abstract
Pulmonary arterial hypertension (PH) and chronic kidney disease (CKD) both profoundly impact patient outcomes, whether as primary disease states or as co-morbid conditions. PH is a common co-morbidity in CKD and vice versa. A growing body of literature describes the epidemiology of PH secondary to chronic kidney disease and end-stage renal disease (ESRD) (WHO group 5 PH). But, there are only limited data on the epidemiology of kidney disease in group 1 PH (pulmonary arterial hypertension [PAH]). The purpose of this review is to summarize the current data on epidemiology and discuss potential disease mechanisms and management implications of kidney dysfunction in PAH. Kidney dysfunction, determined by serum creatinine or estimated glomerular filtration rate, is a frequent co-morbidity in PAH and impaired kidney function is a strong and independent predictor of mortality. Potential mechanisms of PAH affecting the kidneys are increased venous congestion, decreased cardiac output, and neurohormonal activation. On a molecular level, increased TGF-β signaling and increased levels of circulating cytokines could have the potential to worsen kidney function. Nephrotoxicity does not seem to be a common side effect of PAH-targeted therapy. Treatment implications for kidney disease in PAH include glycemic control, lifestyle modification, and potentially Renin-Angiotensin-Aldosterone System (RAAS) blockade.
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Affiliation(s)
- N P Nickel
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - J M O'Leary
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - E L Brittain
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J P Fessel
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - R T Zamanian
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - J D West
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - E D Austin
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
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64
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Which prognostic factors should be used in pulmonary arterial hypertension in elderly patients? JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2017; 14:28-34. [PMID: 28270839 PMCID: PMC5329730 DOI: 10.11909/j.issn.1671-5411.2017.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In recent times, the prevalence of pulmonary arterial hypertension (PAH) is more commonly seen among elderly populations. The increased prevalence of hypertension, diabetes, obesity, arterial stiffness, as well as diastolic dysfunction, may cause endothelial dysfunction and affect pulmonary vasculature. Furthermore, older patients have certain differences in clinical characteristics and outcomes. In this article, the special characteristics of aging in PAH patients have been reviewed, while the risk predictors of elderly patients are also discussed.
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65
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Lewis GD, Ngo D, Hemnes AR, Farrell L, Domos C, Pappagianopoulos PP, Dhakal BP, Souza A, Shi X, Pugh ME, Beloiartsev A, Sinha S, Clish CB, Gerszten RE. Metabolic Profiling of Right Ventricular-Pulmonary Vascular Function Reveals Circulating Biomarkers of Pulmonary Hypertension. J Am Coll Cardiol 2016; 67:174-189. [PMID: 26791065 DOI: 10.1016/j.jacc.2015.10.072] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/06/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pulmonary hypertension and associated right ventricular (RV) dysfunction are important determinants of morbidity and mortality, which are optimally characterized by invasive hemodynamic measurements. OBJECTIVES This study sought to determine whether metabolite profiling could identify plasma signatures of right ventricular-pulmonary vascular (RV-PV) dysfunction. METHODS We measured plasma concentrations of 105 metabolites using targeted mass spectrometry in 71 individuals (discovery cohort) who underwent comprehensive physiological assessment with right-sided heart catheterization and radionuclide ventriculography at rest and during exercise. Our findings were validated in a second cohort undergoing invasive hemodynamic evaluations (n = 71), as well as in an independent cohort with or without known pulmonary arterial (PA) hypertension (n = 30). RESULTS In the discovery cohort, 21 metabolites were associated with 2 or more hemodynamic indicators of RV-PV function (i.e., resting right atrial pressure, mean PA pressure, pulmonary vascular resistance [PVR], and PVR and PA pressure-flow response [ΔPQ] during exercise). We identified novel associations of RV-PV dysfunction with circulating indoleamine 2,3-dioxygenase (IDO)-dependent tryptophan metabolites (TMs), tricarboxylic acid intermediates, and purine metabolites and confirmed previously described associations with arginine-nitric oxide metabolic pathway constituents. IDO-TM levels were inversely related to RV ejection fraction and were particularly well correlated with exercise PVR and ΔPQ. Multisite sampling demonstrated transpulmonary release of IDO-TMs. IDO-TMs also identified RV-PV dysfunction in a validation cohort with known risk factors for pulmonary hypertension and in patients with established PA hypertension. CONCLUSIONS Metabolic profiling identified reproducible signatures of RV-PV dysfunction, highlighting both new biomarkers and pathways for further functional characterization.
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Affiliation(s)
- Gregory D Lewis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts.
| | - Debby Ngo
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna R Hemnes
- Vanderbilt University Pulmonary Unit, Nashville, Tennessee
| | - Laurie Farrell
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carly Domos
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul P Pappagianopoulos
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bishnu P Dhakal
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amanda Souza
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Xu Shi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Arkadi Beloiartsev
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sumita Sinha
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Clary B Clish
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Robert E Gerszten
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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66
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Lala A, Pinney SP. Recognizing Pulmonary Hypertension and Right Ventricular Dysfunction in Heart Failure. Prog Cardiovasc Dis 2016; 58:416-24. [PMID: 26780235 DOI: 10.1016/j.pcad.2016.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension (PH) in the setting of left heart disease (LHD) or heart failure (HF) is the most common form of PH, yet its prevalence is underappreciated. Varying terminology possibly leads to misconceptions in pathophysiology, diagnosis and management. The accurate diagnosis of PH due to LHD is contingent upon hemodynamic assessment via right heart catheterization, however due to limitations in access, comprehensive echocardiography and integrative scoring systems are frequently used. When present in the setting of PH due to LHD, right ventricular dysfunction (RVD) confers a poor clinical prognosis. The management of RVD is directed towards treating underlying HF and/or valvular disease. Implantable hemodynamic monitors may offer opportunity to obtain longitudinal information to increase diagnostic accuracy as well as monitor the effect of treatment of PH in the setting of HF with and without the presence of RVD.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY.
| | - Sean P Pinney
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY
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67
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Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL. Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society. Circulation 2015; 132:2037-99. [PMID: 26534956 DOI: 10.1161/cir.0000000000000329] [Citation(s) in RCA: 686] [Impact Index Per Article: 76.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Child
- Child, Preschool
- Combined Modality Therapy
- Diagnostic Imaging/methods
- Disease Management
- Extracorporeal Membrane Oxygenation
- Genetic Counseling
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/therapy
- Humans
- Hypertension, Pulmonary/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/genetics
- Hypertension, Pulmonary/therapy
- Infant
- Infant, Newborn
- Lung/embryology
- Lung Transplantation
- Nitric Oxide/administration & dosage
- Nitric Oxide/therapeutic use
- Oxygen Inhalation Therapy
- Persistent Fetal Circulation Syndrome/diagnosis
- Persistent Fetal Circulation Syndrome/therapy
- Postoperative Complications/therapy
- Respiration, Artificial/adverse effects
- Respiration, Artificial/methods
- Ventilator-Induced Lung Injury/prevention & control
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68
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Serum Caveolin-1 as a Novel Biomarker in Idiopathic Pulmonary Artery Hypertension. BIOMED RESEARCH INTERNATIONAL 2015; 2015:173970. [PMID: 26539466 PMCID: PMC4619756 DOI: 10.1155/2015/173970] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/16/2015] [Accepted: 08/18/2015] [Indexed: 12/16/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease but with significant morbidity and high mortality. There is no specific way to diagnose PAH. Thus, an easy used with good sensitivity and specificity biomarker of PAH is highly desirable to aid in the screening, diagnosis, and follow-up. Caveolin-1 (Cav1) is the structural protein of caveolae and is highly expressed in type I pneumocytes. Lungs tissues from idiopathic PAH (IPAH) patients showed decreased expression of Cav1 in vascular endothelial cells. Therefore, we developed a direct sandwich immunoassay for the determination of Cav1 in IAPH patient's serum. The result disclosed serum Cav1 level was significantly lower in IPAH than control groups. Using serum Cav1, 17.17 pg/mL as a cutoff value, the sensitivity was 0.59 and the specificity was 1.0. There were two major findings in our results. First, serum Cav1 might be a novel biomarker in the diagnosis of IPAH with fare sensitivity and good specificity. Second, Cav1 might be used to make differential diagnosis between COPD-PH and IPAH group.
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69
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Zheng YG, Yang T, He JG, Chen G, Liu ZH, Xiong CM, Gu Q, Ni XH, Zhao ZH. Plasma soluble ST2 levels correlate with disease severity and predict clinical worsening in patients with pulmonary arterial hypertension. Clin Cardiol 2015; 37:365-70. [PMID: 25068163 DOI: 10.1002/clc.22262] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Soluble suppression of tumorigenicity (sST2) has been proposed to be a marker for biomechanical strain and a possible predictor of mortality in patients with chronic heart failure. The use of sST2 in pulmonary arterial hypertension (PAH) has not been well defined. HYPOTHESIS Plasma sST2 levels may correlate with the disease severity and predict clinical worsening in PAH. METHODS We performed a cohort study of 40 idiopathic PAH patients with data on demographics, exercise capacity, echocardiographic parameters, laboratory tests, hemodynamics, and medications. Plasma sST2 was assessed with the high-sensitivity ST2 ELISA kit at diagnostic catheterization. All patients were followed up from the date of blood sampling. The endpoint was clinical worsening. RESULTS sST2 was significantly elevated in patients with idiopathic PAH compared with control subjects (28.9 ± 13.9 vs 20.7 ± 7.5 ng/mL, P = 0.003). Pearson correlation analysis revealed that sST2 levels correlated with cardiac index (r = -0.534, P = 0.000) and pulmonary vascular resistance (r = 0.350, P = 0.027), and could reflect disease severity of PAH. After a mean follow-up of 14 ± 5 months, 12 patients showed clinical worsening. Receiver operating characteristic analysis suggested that sST2 levels >31.4 ng/mL discriminated clinical worsening with a sensitivity and specificity of 83.3% and 78.6%, respectively. Kaplan-Meier analysis showed that higher sST2 levels (>31.4 ng/mL) were associated with poor clinical outcomes (P = 0.008). Multivariate Cox regression analysis showed that sST2 was an independent predictor of clinical worsening (hazard ratio: 6.067, 95% confidence interval: 1.317-27.948, P = 0.021). CONCLUSIONS sST2 correlates with disease severity and is a significant predictor of clinical worsening in patients with PAH.
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70
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2015; 46:903-75. [DOI: 10.1183/13993003.01032-2015] [Citation(s) in RCA: 1929] [Impact Index Per Article: 214.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
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71
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2015; 37:67-119. [DOI: 10.1093/eurheartj/ehv317] [Citation(s) in RCA: 3916] [Impact Index Per Article: 435.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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72
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Nies MK, Ivy DD, Everett AD. The untapped potential of proteomic analysis in pediatric pulmonary hypertension. Proteomics Clin Appl 2015; 8:862-74. [PMID: 25348110 DOI: 10.1002/prca.201400067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/21/2014] [Accepted: 10/21/2014] [Indexed: 11/10/2022]
Abstract
Analysis of the human proteome has become increasingly sophisticated, and offers invaluable potential insight into the pathophysiology of human disease. The increasing standardization of methods, speed, and sophistication of mass spectrometric analysis, availability of reliable antibodies, and dissemination of information among the scientific community has allowed for exponential growth of our knowledge base. The continued effort to provide a molecular explanation for future medical applications based on biomarker discovery is epitomized by the outstanding efforts of the human proteome project, whose goal is to generate a map of the human proteome. However, proteomic analysis is underrepresented in pediatric illness; given the unique challenges of research in the pediatric population, proteomic analysis represents enormous untapped potential, especially in the further elucidation of the pathophysiology of rare diseases such as pulmonary hypertension (PH). In this article, we will describe the unique challenge of pediatric research, the importance of alternative avenues such as proteomics for in-depth analysis of pediatric pathobiology at the cellular level, the specific need for proteomic investigation of pediatric PH, the current status of PH proteomics, and future directions.
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Affiliation(s)
- Melanie K Nies
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
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73
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Castillo-Martínez D, Marroquín-Fabián E, Lozada-Navarro AC, Mora-Ramírez M, Juárez M, Sánchez-Muñoz F, Vargas-Barrón J, Sandoval J, Amezcua-Guerra LM. Levels of uric acid may predict the future development of pulmonary hypertension in systemic lupus erythematosus: a seven-year follow-up study. Lupus 2015; 25:61-6. [PMID: 26306740 DOI: 10.1177/0961203315600539] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/08/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this paper is to assess whether pulmonary hypertension (PH) may be detected at one point in time or longitudinally predicted by serum uric acid (sUA) levels in systemic lupus erythematosus (SLE). METHODS We conducted a post-hoc analysis of a long-term followed cohort of Mexican SLE patients. Echocardiography-based definitions of PH by the ESC/ERS/ISHLT and its associations with clinical and laboratory data on enrollment were studied. Especially, the impact that sUA levels at baseline may have on the future development of PH in patients with normal pulmonary artery systolic pressure (PASP) was explored. RESULTS Out of the 156 SLE patients originally enrolled in the cohort, 44 met the inclusion criteria for the present study and were grouped as having (n =10) or not having (n = 34) PH. At baseline, sUA levels of 5.83 ± 1.79 and 5.82 ± 1.97 mg/dl (p = ns) were found in patients with and without PH, respectively. No association between PASP and other markers was found. In patients with normal PASP, the presence of sUA ≥ 7 mg/dl at baseline predicted future development of PH (relative risk 8.5, 1.0009 to 72; p = 0.04). CONCLUSION In SLE, sUA levels at one point in time are useless to detect PH. However, steady hyperuricemia may predict the future development of PH in patients with normal PASP at baseline.
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Affiliation(s)
- D Castillo-Martínez
- Department of Dermatology, Hospital General de Zona 32 Villa Coapa, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - E Marroquín-Fabián
- Department of Rheumatology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - A C Lozada-Navarro
- Department of Rheumatology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - M Mora-Ramírez
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - M Juárez
- Department of Rheumatology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - F Sánchez-Muñoz
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - J Vargas-Barrón
- Division of Research, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - J Sandoval
- Division of Research, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - L M Amezcua-Guerra
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico Department of Health Care, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico LaSalle University School of Medicine, Mexico City, Mexico
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74
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Hyperuricemia: An Early Marker for Severity of Illness in Sepsis. Int J Nephrol 2015; 2015:301021. [PMID: 26294973 PMCID: PMC4532866 DOI: 10.1155/2015/301021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/29/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023] Open
Abstract
Background. Uric acid can acutely activate various inflammatory transcription factors. Since high levels of oxyradicals and lower antioxidant levels in septic patients are believed to result in multiorgan failure, uric acid levels could be used as a marker of oxidative stress and poor prognosis in patients with sepsis. Design. We conducted a prospective cohort study on Medical Intensive Care Unit (MICU) patients and hypothesized that elevated uric acid in patients with sepsis is predictive of greater morbidity. The primary end point was the correlation between hyperuricemia and the morbidity rate. Secondary end points were Acute Kidney Injury (AKI), mortality, Acute Respiratory Distress Syndrome (ARDS), and duration of stay. Results. We enrolled 144 patients. 54 (37.5%) had the primary end point of hyperuricemia. The overall morbidity rate was 85.2%. The probability of having hyperuricemia along with AKI was 68.5% and without AKI was 31.5%. Meanwhile the probability of having a uric acid value <7 mg/dL along with AKI was 18.9% and without AKI was 81.1% (p value < 0.0001). Conclusion. We report that elevated uric acid levels on arrival to the MICU in patients with sepsis are associated with poor prognosis. These patients are at an increased risk for AKI and ARDS.
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75
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MacKenzie AM, Peacock AJ. Medical Therapies for the Treatment of Pulmonary Arterial Hypertension: How Do We Choose? Curr Hypertens Rep 2015; 17:56. [DOI: 10.1007/s11906-015-0560-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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76
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Jardim C, Souza R. Biomarkers and Prognostic Indicators in Pulmonary Arterial Hypertension. Curr Hypertens Rep 2015; 17:556. [DOI: 10.1007/s11906-015-0556-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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77
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Byrne TJ. A "cure" for preeclampsia: Improving neonatal outcomes by overcoming excess fetal placental vascular resistance. Med Hypotheses 2015; 85:311-9. [PMID: 26105573 DOI: 10.1016/j.mehy.2015.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 03/10/2015] [Accepted: 06/02/2015] [Indexed: 02/01/2023]
Abstract
From a broad perspective there are only three arterial systems that respond to relative hypoxia with vasoconstriction. They are the placental, the pulmonic and the renal vascular beds. The renal system's adaptation to hypoxia is markedly different from the other two circulatory beds and will not be further considered here. Regional vasoconstriction is adaptive in the placenta and lung because it redirects red blood cells from areas of relative hypoxia to more oxygenated areas thereby maximizing oxygen uptake for a given cardiac output. The fetal placental and pulmonary vascular systems are unique because their smooth muscle cells have a unique and possibly identical potassium channel that responds to hypoxia by closing, thereby depolarizing the cell membrane allowing calcium ion influx and muscle contraction. It may be that a variety of initial causes of temporary or local placental hypoxia initiate a cascade of first fetal placental then maternal vasoconstriction and endothelial activation leading to the clinical syndrome we call preeclampsia. The response cascades seen in preeclampsia, which for purposes of this article I will abbreviate as (PECL), after development of widespread vasoconstriction, will also be seen to be identical or at least parallel in pulmonary hypertension (PAH). This means that some or all of the pharmacotherapies presently used, tested or considered in early PAH may also have a therapeutic effect in PECL by reducing fetal placental arterial resistance thereby increasing fetal placental flow. This would allow increased oxygen and other nutrient uptake and possibly increased fetal cardiac output in the face of reduced fetal cardiac work. This may allow a delay in delivery in which fetuses grow and are better oxygenated in preterm PECL, improving neonatal outcomes.
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Affiliation(s)
- T J Byrne
- Maternal Fetal Medicine, Harlem Hospital, 506 Lenox Avenue, New York, NY 10037, USA.
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78
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Circulating biomarkers in pulmonary arterial hypertension: Update and future direction. J Heart Lung Transplant 2015; 34:282-305. [DOI: 10.1016/j.healun.2014.12.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 12/29/2022] Open
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79
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Embarak S, Sileem AE, Abdrabboh M, Mokhtar A. Serum uric acid as a biomarker for prediction of outcomes of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2014. [DOI: 10.4103/1687-8426.145703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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80
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Baldi F, Fuso L, Arrighi E, Valente S. Optimal management of pulmonary arterial hypertension: prognostic indicators to determine treatment course. Ther Clin Risk Manag 2014; 10:825-39. [PMID: 25328398 PMCID: PMC4199557 DOI: 10.2147/tcrm.s48920] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rapidly progressive pulmonary vascular disease with a multifactorial etiopathogenesis that can result in right-sided heart failure and death. A number of studies indicate that an early therapeutic intervention yields better results on disease progression as compared to delayed treatment. In this review, we will analyze treatment strategies that may be used for monitoring disease progression and for guiding treatment decisions. Several factors (ie, symptoms, functional class, exercise capacity as assessed by a walking test and cardiopulmonary stress testing, hemodynamic parameters, cardiac magnetic resonance imaging, and plasma levels of biochemical markers) have been prognostic of survival. These indicators may be used both at the time of diagnosis and during treatment follow-up. No resolutive therapy is currently available for PAH; however, in the last decade, the advent of specific pharmacological treatments has given new hope to patients suffering from this debilitating disease with a poor prognosis. Combination drug therapies offer increased benefits over monotherapy, and current guidelines recommend a sequential “add on” design approach for patients in functional class II–IV. The goal-oriented “treat to target” therapy sets the timing for treatment escalation in case of inadequate response to currently known prognostic indicators. To date, further longitudinal studies should be urgently conducted to identify new goals that may improve therapeutic strategies in order to optimize personalized treatment in PAH patients.
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Affiliation(s)
- Fabiana Baldi
- Pulmonary Medicine Unit, Catholic University, Rome, Italy
| | - Leonello Fuso
- Pulmonary Medicine Unit, Catholic University, Rome, Italy
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81
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Gashouta MA, Humbert M, Hassoun PM. Update in systemic sclerosis-associated pulmonary arterial hypertension. Presse Med 2014; 43:e293-304. [DOI: 10.1016/j.lpm.2014.06.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/18/2014] [Indexed: 01/08/2023] Open
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82
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Matsubara H, Ogawa A. Treatment of idiopathic/hereditary pulmonary arterial hypertension. J Cardiol 2014; 64:243-9. [DOI: 10.1016/j.jjcc.2014.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/11/2014] [Indexed: 01/09/2023]
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83
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84
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Rame JE, Vaidya A. Disease progression in pulmonary arterial hypertension: refining the phenotype with a prognostic biomarker profile from collagen. JACC. HEART FAILURE 2014; 2:422-424. [PMID: 25023821 DOI: 10.1016/j.jchf.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/07/2014] [Indexed: 06/03/2023]
Affiliation(s)
- J Eduardo Rame
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Anjali Vaidya
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania
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85
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Minai OA. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Biomarkers in pulmonary arterial hypertension. Ann Thorac Med 2014; 9:S92-7. [PMID: 25077003 PMCID: PMC4114275 DOI: 10.4103/1817-1737.134047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 12/22/2022] Open
Abstract
The biomarker is an indicaror of a biological or pathological process. Clinical observations, measures or environmental events, or measured laboratory values can all be biomarkers in the appropriate setting. An ideal biomarker reflects the underlying biological process, predicts clinical events, is easily obtainable, is reproducible and is not prohibitively expensive. This typically requires validation in longitudinal cohort studies. Biomarkers may help understand the pathological mechanisms responsible for the disease, help as screening tools, predict disease worsening or decline, and determine adequacy of response to therapeutic interventions.
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Affiliation(s)
- Omar A Minai
- Associate Professor of Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
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86
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Idrees MM, Saleemi S, Azem MA, Aldammas S, Alhazmi M, Khan J, Gari A, Aldabbagh M, Sakkijha H, Aldalaan A, Alnajashi K, Alhabeeb W, Nizami I, Kouatli A, Chehab M, Tamimi O, Banjar H, Kashour T, Lopes A, Minai O, Hassoun P, Pasha Q, Mayer E, Butrous G, Bhagavathula S, Ghio S, Swiston J, Boueiz A, Tonelli A, Levy RD, Hoeper M, Levy RD. Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates. Ann Thorac Med 2014; 9:S1-S15. [PMID: 25076987 PMCID: PMC4114283 DOI: 10.4103/1817-1737.134006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 11/26/2022] Open
Abstract
The Saudi Association for Pulmonary Hypertension (previously called Saudi Advisory Group for Pulmonary Hypertension) has published the first Saudi Guidelines on Diagnosis and Treatment of Pulmonary Arterial Hypertension back in 2008.[1] That guideline was very detailed and extensive and reviewed most aspects of pulmonary hypertension (PH). One of the disadvantages of such detailed guidelines is the difficulty that some of the readers who just want to get a quick guidance or looking for a specific piece of information might face. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and helpful to clinicians dealing with PH patients to select the best management strategies for the typical patient suffering from a specific condition. This Guideline was designed to provide recommendations for problems frequently encountered by practicing clinicians involved in management of PH. This publication targets mainly adult and pediatric PH-treating physicians, but can also be used by other physicians interested in PH.
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Affiliation(s)
- Majdy M Idrees
- Department of Pulmonary Medicine, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sarfraz Saleemi
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - M Ali Azem
- Department of Critical Care Medicine, King Fahd Medical Center, Dammam, Saudi Arabia
| | - Saleh Aldammas
- Department of Pulmonary Medicine, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Manal Alhazmi
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Javid Khan
- Department of Pulmonary Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Abdulgafour Gari
- Department of Pulmonary Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Maha Aldabbagh
- Department of Pediatric, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Husam Sakkijha
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Abdulla Aldalaan
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Alnajashi
- Department of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Waleed Alhabeeb
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Imran Nizami
- Department of Organ Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Amjad Kouatli
- Department of Pediatric Cardiology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - May Chehab
- Department of Pediatric Intensive Care, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Omar Tamimi
- Department of Pediatric Cardiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hanaa Banjar
- Department of Pediatric, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Science, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Antonio Lopes
- Department of Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Omar Minai
- Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Paul Hassoun
- Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qadar Pasha
- Department of CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Ghazwan Butrous
- Department of Cardiopulmonary science, Imperial College, London, UK
| | | | - Stefano Ghio
- Department of Fondazione IR IRCCS Policlinico San Matteo, Pavia, Italy
| | - John Swiston
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adel Boueiz
- Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Robert D Levy
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marius Hoeper
- Department of Pulmonary Hypertension Program, Hanover Medical School, Hanover, Germany
| | - Rober D Levy
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
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87
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Ploegstra MJ, Douwes JM, Roofthooft MT, Zijlstra WM, Hillege HL, Berger RM. Identification of treatment goals in paediatric pulmonary arterial hypertension. Eur Respir J 2014; 44:1616-26. [DOI: 10.1183/09031936.00030414] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To be able to design goal-oriented treatment strategies in paediatric pulmonary arterial hypertension (PAH), we aimed to identify treatment goals by investigating the prognostic value of treatment-induced changes in noninvasive predictors of transplant-free survival.66 consecutive, treatment-naïve paediatric PAH patients in the Dutch National Network for Paediatric Pulmonary Hypertension who started taking PAH-targeted drugs between January 2000 and April 2013 underwent prospective, standardised follow-up. Clinical, biochemical and echocardiographic measures were longitudinally collected at treatment initiation and follow-up, and their respective predictive values for transplant-free survival were assessed. Furthermore, the predictive values of treatment-induced changes were assessed.From the identified set of baseline predictors, the variables World Health Organization functional class (WHO-FC), N-terminal pro-brain natriuretic peptide (NT-proBNP) and tricuspid annular plane systolic excursion (TAPSE) were identified as follow-up predictors in which treatment-induced changes were associated with survival. Patients in whom these variables improved after treatment showed better survival (p<0.002).Therefore, WHO-FC, NT-proBNP and TAPSE are not only predictors of transplant-free survival in paediatric PAH but can also be used as treatment goals, as treatment-induced improvements in these variables are associated with improved survival. The identification of these variables allows for the introduction of goal-oriented treatment strategies in paediatric PAH.
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88
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McGlinchey N, Peacock AJ. Endpoints in PAH clinical trials in the era of combination therapy: how do we decide whether something is working without going bankrupt? Drug Discov Today 2014; 19:1236-40. [PMID: 24814434 DOI: 10.1016/j.drudis.2014.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/30/2014] [Indexed: 11/29/2022]
Abstract
There has been substantial progress in the treatment of pulmonary arterial hypertension using specific disease-targeted therapies. As the number of agents available grows, and as new treatment strategies emerge, it is essential that the endpoints we use to assess efficacy are sufficiently meaningful and sensitive enough to detect changes that are often subtle. Although the six-minute walk has been the traditional primary endpoint in clinical trials, there is now a move towards more patient-centred composite endpoints such as time to clinical worsening. These endpoints need to be more clearly defined and universally applied so as to make direct comparison between new drugs and new combinations possible.
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Affiliation(s)
- Neil McGlinchey
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, G81 4HX, UK
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, G81 4HX, UK.
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89
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Endothelin antagonism and uric acid levels in pulmonary arterial hypertension: Clinical associations. J Heart Lung Transplant 2014; 33:521-7. [DOI: 10.1016/j.healun.2014.01.853] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 11/18/2013] [Accepted: 01/16/2014] [Indexed: 02/07/2023] Open
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90
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Chen G, Yang T, Gu Q, Ni XH, Zhao ZH, Ye J, Meng XM, Liu ZH, He JG, Xiong CM. Elevated plasma YKL-40 as a prognostic indicator in patients with idiopathic pulmonary arterial hypertension. Respirology 2014; 19:608-15. [PMID: 24689969 DOI: 10.1111/resp.12283] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/05/2013] [Accepted: 02/04/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Guo Chen
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Qing Gu
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Xin-Hai Ni
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Jue Ye
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Xian-Min Meng
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Jian-Guo He
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease; Fuwai Hospital; National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
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91
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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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92
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Kim KJ, Baek IW, Park YJ, Yoon CH, Kim WU, Cho CS. High levels of uric acid in systemic lupus erythematosus is associated with pulmonary hypertension. Int J Rheum Dis 2014; 18:524-32. [DOI: 10.1111/1756-185x.12262] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ki-Jo Kim
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - In-Woon Baek
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Yune-Jung Park
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Chong-Hyeon Yoon
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Wan-Uk Kim
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Chul-Soo Cho
- Division of Rheumatology; Department of Internal Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
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93
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Sulica R, Poon M. Medical therapeutics for pulmonary arterial hypertension: from basic science and clinical trial design to evidence-based medicine. Expert Rev Cardiovasc Ther 2014; 3:347-60. [PMID: 15853607 DOI: 10.1586/14779072.3.2.347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pulmonary arterial hypertension is a severe disease with poor prognosis, caused by obliteration of the pulmonary vasculature as a result of pulmonary-vascular remodeling, active vasoconstriction and in situ thrombosis. Left untreated, pulmonary arterial hypertension results in right-ventricular failure and death. There has been dramatic progress in the treatment of pulmonary arterial hypertension during recent years. A remarkable number of randomized-controlled trials with agents known to target specific abnormalities present in pulmonary arterial hypertension have been completed. Most commonly, therapeutic efficacy was judged by the ability of the drug under study to improve exercise capacity and to decrease the rate of severe complications. Completed clinical trials have mainly evaluated patients with relatively advanced disease. Despite these advances, responses to therapy in pulmonary arterial hypertension are not uniformly favorable and frequently incomplete. In addition, the methods of delivery and the adverse effect profile of the currently available pulmonary arterial hypertension-specific drugs create further management difficulties. Based on newly identified pathobiologic abnormalities in the pulmonary vasculature, future studies are likely to focus on the discovery of new therapeutic targets. Clinical trial design will continue to evolve in an attempt to enable inclusion of patients with less advanced disease and evaluation of treatment combinations or comparisons of the currently approved drugs.
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Affiliation(s)
- Roxana Sulica
- Mount Sinai School of Medicine, 1 Gustave L Levy Place, Box 1030, New York, NY 10029, USA.
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95
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Myers PO, Tissot C, Beghetti M. Assessment of operability of patients with pulmonary arterial hypertension associated with congenital heart disease. Circ J 2013; 78:4-11. [PMID: 24225339 DOI: 10.1253/circj.cj-13-1263] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a common complication of congenital heart disease, and is now predominantly among patients with uncorrected left-to-right shunts. A growing population is characterized by persistent or recurrent PAH after surgical or interventional correction of left-to-right shunts; the latter having a worse prognosis than other forms of PAH associated with congenital heart disease. New treatments for PAH have been shown to be effective in improving PAH exercise capacity and hemodynamics, raising the hope for making previously inoperable congenital heart defects operable and shifting the framework for the assessment of operability. This review focuses on current methods for assessing operability in PAH associated with congenital heart disease, and the possibility of "treat-and-repair" vs. "repair-and-treat" strategies for patients with inoperable or borderline PAH.
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Affiliation(s)
- Patrick O Myers
- Division of Cardiovascular Surgery, Geneva University Hospitals & School of Medicine
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96
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Foris V, Kovacs G, Tscherner M, Olschewski A, Olschewski H. Biomarkers in pulmonary hypertension: what do we know? Chest 2013; 144:274-283. [PMID: 23880678 DOI: 10.1378/chest.12-1246] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Pulmonary hypertension (PH) is a hemodynamic condition that has a poor prognosis and can lead to right-sided heart failure. It may result from common diseases such as left-sided heart or lung disease or may present as the rare entity of idiopathic pulmonary arterial hypertension. Biomarkers that specifically indicate the pathologic mechanism, the severity of the disease, and the treatment response would be ideal tools for the management of PH. In this review, markers related to heart failure, inflammation, hemostasis, remodeling, and endothelial cell-smooth muscle cell interaction are discussed, and their limitations are emphasized. Anemia, hypocarbia, elevated uric acid, and C-reactive protein levels are unspecific markers of disease severity. Brain natriuretic peptide and N-terminal fragment of pro-brain natriuretic peptide have been recommended in current guidelines, whereas other prognostic markers, such as growth differentiation factor-15, osteopontin, and red cell distribution width, are emerging. Chemokines of the CC family and matrix metalloproteases have been linked to the vascular pathologic mechanisms, and new markers such as apelin have been described. Circulating endothelial and progenitor cells have received much attention as markers of disease activity, but with controversial findings. A lack of standards for cell isolation and characterization methods and differences in the pathologic mechanisms of the investigated patients may have contributed to the discrepancies. In conclusion, although several promising markers have been identified over the past few years, the development of more specific markers, standardization, and prospective validation are warranted.
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Affiliation(s)
- Vasile Foris
- Ludwig Boltzmann Institute for Lung Vascular Research, the Medical University of Graz, Graz, Austria; Department of Internal Medicine, Division of Pulmonology, the Medical University of Graz, Graz, Austria
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, the Medical University of Graz, Graz, Austria; Department of Internal Medicine, Division of Pulmonology, the Medical University of Graz, Graz, Austria
| | - Maria Tscherner
- Ludwig Boltzmann Institute for Lung Vascular Research, the Medical University of Graz, Graz, Austria; Department of Internal Medicine, Division of Pulmonology, the Medical University of Graz, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, the Medical University of Graz, Graz, Austria; Department of Anesthesia and Intensive Care, Experimental Anesthesiology, the Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, the Medical University of Graz, Graz, Austria; Department of Internal Medicine, Division of Pulmonology, the Medical University of Graz, Graz, Austria.
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97
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Hirotsu C, Tufik S, Guindalini C, Mazzotti DR, Bittencourt LR, Andersen ML. Association between uric acid levels and obstructive sleep apnea syndrome in a large epidemiological sample. PLoS One 2013; 8:e66891. [PMID: 23826169 PMCID: PMC3691311 DOI: 10.1371/journal.pone.0066891] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/10/2013] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Recurrent hypoxia, which is associated with obstructive sleep apnea syndrome (OSAS), leads to an increase in the degradation of adenosine triphosphatase into xanthine, which in turn increases uric acid concentrations. OBJECTIVE The current study aimed to determine whether an association exists between OSAS and uric acid levels in the peripheral blood from a representative population of Sao Paulo (Brazil). METHODS A population-based survey adopting a probabilistic 3-stage cluster sample of Sao Paulo was used to represent the population according to gender, age, and socioeconomic class. A total of 1,042 volunteers underwent polysomnography recordings for OSAS diagnosis, blood pressure assessment, and biochemical blood analysis, and answered questionnaires. RESULTS Uric acid levels were correlated with most important risk factors for OSAS, such as AHI, desaturation time and index, minimum oxyhemoglobin saturation (SpO2), blood pressure, cholesterol, BMI, triglycerides and arousal, and with OSAS itself. Also, uric acid was increased in OSAS volunteers even after controlling for all confounders. Hyperuricemic volunteers presented lower mean and minimum SpO2 and increased desaturation index. Importantly, minimum SpO2 was a significant predictor of uric acid levels, which in turn was considered an independent predictor for OSAS in the binary logistic model. However, a ROC curve analysis for establishing cut-off points for uric acid levels as a biomarker of OSAS revealed moderate sensitivity and specificity. CONCLUSION A strong association was found between uric acid levels and OSAS in a representative sample of the population of Sao Paulo. Although they do not qualify for a biomarker alone, uric acid levels may be involved in OSAS severity and should be considered in sleep apnea management in the future.
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Affiliation(s)
- Camila Hirotsu
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Sergio Tufik
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Camila Guindalini
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Diego R. Mazzotti
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Lia R. Bittencourt
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Monica L. Andersen
- Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
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98
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Renard S, Paulin R, Breuils-Bonnet S, Simard S, Pibarot P, Bonnet S, Provencher S. Pim-1: A new biomarker in pulmonary arterial hypertension. Pulm Circ 2013; 3:74-81. [PMID: 23662177 PMCID: PMC3641743 DOI: 10.4103/2045-8932.109917] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Provirus integration site for Moloney murine leukemia virus (Pim-1) is an oncoprotein overexpressed in lungs from pulmonary arterial hypertension (PAH) patients and involved in cell proliferation via the activation of the NFAT/STAT3 signaling pathway. We hypothesized that Pim-1 plasma levels would predict the presence of PAH and correlate with disease severity. Pim-1 plasma levels were measured at the time of catheterization in 49 PAH patients, including nonvasoreactive ( n = 19) and vasoreactive idiopathic PAH (n = 5), and PAH related to connective tissue disease (n = 16) and congenital heart disease (n = 9). Fifty controls were also recruited. The capacity of Pim-1 to discriminate PAH from controls and its association with disease severity were assessed. Pim-1 plasma levels were higher in PAH than in controls (9.6 ± 4.0 vs. 7.2 ± 2.4 ng/mL, P < 0.01). Pim-1 appropriately discriminated proliferative PAH from controls (AUC = 0.78 to 0.94 using ROC curves). Among PAH patients, Pim-1 correlated with traditional markers of PAH severity. The 1-year survival was 97% and 47% for PAH patients with baseline Pim-1 levels lower and higher than 11.1 ng/mL, respectively (HR 11.4 (3.3-39.7); P < 0.01). After adjustment for hemodynamic and biochemical variables, Pim-1 levels remained an independent predictor of mortality (P < 0.01). Pim-1 is a promising new biomarker in PAH.
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Affiliation(s)
- Sébastien Renard
- Pulmonary Hypertension Group of the Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada ; Cardiology, Center Hospital University Timone, Public Assistance Hospitals of Marseille, Aix-Marseille University, Marseille, France
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99
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Hassoun PM, Nikkho S, Rosenzweig EB, Moreschi G, Lawrence J, Teeter J, Meier C, Ghofrani AH, Minai O, Rinaldi P, Michelakis E, Oudiz RJ. Updating clinical endpoint definitions. Pulm Circ 2013; 3:206-16. [PMID: 23662199 PMCID: PMC3641732 DOI: 10.4103/2045-8932.109920] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The 6-Minute Walk Distance (6-MWD) has been the most utilized endpoint for judging the efficacy of pulmonary arterial hypertension (PAH) therapy in clinical trials conducted over the past two decades. Despite its simplicity, widespread use in recent trials and overall prognostic value, the 6-MWD has often been criticized over the past several years and pleas from several PAH experts have emerged from the literature to find alternative endpoints that would be more reliable in reflecting the pulmonary vascular resistance as well as cardiac status in PAH and their response to therapy. A meeting of PAH experts and representatives from regulatory agencies and pharmaceutical companies was convened in early 2012 to discuss the validity of current as well as emerging valuable endpoints. The current work represents the proceedings of the conference.
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100
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Pregnancy and hemolysis, elevated liver enzymes and low platelet count syndrome in patients with Eisenmenger's syndrome. Am J Med Sci 2013; 346:385-9. [PMID: 23656922 DOI: 10.1097/maj.0b013e31829338fb] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Eisenmenger's syndrome is characterized by a right-to-left or bidirectional shunt in congenital heart diseases. Hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, commonly occurring during pregnancy, includes hemolysis, elevated liver enzymes and low platelet counts. HELLP syndrome and pregnancy are extremely rare in patients with Eisenmenger's syndrome. The authors report 4 cases of pregnancy complicated by the HELLP and Eisenmenger's syndrome and describe their initial intervention and the in-hospital outcomes of these cases. Special emphasis is given to elaborate about the hemodynamic monitoring, magnesium sulphate for convulsions, corticosteroid treatment, anticoagulation therapy, management of pulmonary hypertension, the timing of delivery, and blood product transfusion.
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