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Zhu HR, Kuang HY, Li Q, Ji XJ. Effects of oral targeted treatments in pulmonary arterial hypertension: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:915470. [PMID: 35983180 PMCID: PMC9378982 DOI: 10.3389/fcvm.2022.915470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/08/2022] [Indexed: 11/26/2022] Open
Abstract
Background Although pulmonary arterial hypertension (PAH) is a fatal disease, specific drugs have been used to treat PAH. These drugs predominantly target these three pathobiological pathways: Endothelin receptor antagonist (ERA), nitric oxide (NO), and prostanoids pathways. In this review, we aimed to analyze the efficacy and safety of oral targeted treatments for PAH. Methods The national library of medicine (MEDLINE), excerpta medica database (EMBASE), and Cochrane Central Register of Controlled Trials databases were searched. Randomized controlled trials that compared the oral targeted drugs with placebos were selected. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for variables with dichotomous outcomes, and standardized mean differences with continuous outcomes variables. Additionally, the mean of the differences for the 6-min walk distance (6MWD) was analyzed. Results In total, 23 studies involving 7,121 patients were included in this study. These studies show that orally PAH-specific drugs could decrease the risk of clinical worsening events, with an OR of 0.55 (p < 0.001). Furthermore, these drugs could improve exercise capacity, showing a 21.74-m increase in 6MWD (95% CI: 17.53–25.95 m) and cause a greater amelioration of functional class (OR = 0.60, 95% CI: 0.47–0.76). Additionally, subgroup analysis indicated that compared with placebo, ERAs, and drugs in the NO pathway were most effective and safe, which are associated with an improvement in exercise capacity, 6MWD, and worsening events-free survival rate. Conclusion Nitric oxide exhibited the most prominent clinical effect on exercise tolerance. However, in the subgroup analysis, oral targeted drugs of different pathways show applicability to different populations, which highlights the need for precise treatment in the clinical setting. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=297946], identifier [CRD 42022297946].
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Affiliation(s)
- Hui-ru Zhu
- National Clinical Research Center for Child Health and Disorders, Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Hong-yu Kuang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang Li
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-juan Ji
- Department of Ultrasound, Chongqing General Hospital, Chongqing, China
- *Correspondence: Xiao-juan Ji,
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Hendriks PM, van de Groep LD, Veen KM, van Thor MCJ, Meertens S, Boersma E, Boomars KA, Post MC, van den Bosch AE. Prognostic value of brain natriuretic peptides in patients with pulmonary arterial hypertension: A systematic review and meta-analysis. Am Heart J 2022; 250:34-44. [PMID: 35533723 DOI: 10.1016/j.ahj.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/30/2022] [Accepted: 05/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Multiple biomarkers have been investigated in the risk stratification of patients with pulmonary arterial hypertension (PAH). This systematic review and meta-analysis is the first to investigate the prognostic value of (NT-pro)BNP in patients with PAH. METHODS A systematic literature search was performed using MEDLINE, Embase, Web of Science, the Cochrane Library and Google scholar to identify studies on the prognostic value of baseline (NT-pro)BNP levels in PAH. Studies reporting hazard ratios (HR) for the endpoints mortality or lung transplant were included. A random effects meta-analysis was performed to calculate the pooled HR of (NT-pro)BNP levels at the time of diagnosis. To account for different transformations applied to (NT-pro)BNP, the HR was calculated for a 2-fold difference of the weighted mean (NT-pro)BNP level of 247 pmol/L, for studies reporting a HR based on a continuous (NT-pro)BNP measurement. RESULTS Sixteen studies were included, representing 6999 patients (mean age 45.2-65.0 years, 97.3% PAH). Overall, 1460 patients reached the endpoint during a mean follow-up period between 1 and 10 years. Nine studies reported HRs based on cut-off values. The risk of mortality or lung transplant was increased for both elevated NT-proBNP and BNP with a pooled HR based on unadjusted HRs of 2.75 (95%-CI: 1.86-4.07) and 3.87 (95% CI 2.69-5.57) respectively. Six studies reported HRs for (NT-pro)BNP on a continues scale. A 2-fold difference of the weighted mean NT-proBNP resulted in an increased risk of mortality or lung transplant with a pooled HR of 1.17 (95%-CI: 1.03-1.32). CONCLUSIONS Increased levels of (NT-pro)BNP are associated with a significantly increased risk of mortality or lung transplant in PAH patients.
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Affiliation(s)
- Paul M Hendriks
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Respiratory medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Liza D van de Groep
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Kevin M Veen
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mitch C J van Thor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Sabrina Meertens
- Medical Library, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Clinical epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karin A Boomars
- Department of Respiratory medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Utrecht University Medical Center, Utrecht, The Netherlands
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McCarthy BE, McClelland RL, Appleby DH, Moutchia JS, Minhas JK, Min J, Mazurek JA, Smith KA, Fritz JS, Pugliese SC, Urbanowicz RJ, Holmes JH, Palevsky HI, Kawut SM, Al-Naamani N. BMI and Treatment Response in Patients With Pulmonary Arterial Hypertension: A Meta-analysis. Chest 2022; 162:436-447. [PMID: 35247393 PMCID: PMC9470735 DOI: 10.1016/j.chest.2022.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Obesity is increasingly prevalent in pulmonary arterial hypertension (PAH) but is associated with improved survival, creating an "obesity paradox" in PAH. It is unknown if the improved outcomes could be attributable to obese patients deriving a greater benefit from PAH therapies. RESEARCH QUESTION Does BMI modify treatment effectiveness in PAH? STUDY DESIGN AND METHODS Using individual participant data, a meta-analysis was conducted of phase III, randomized, placebo-controlled trials of treatments for PAH submitted for approval to the U.S. Food and Drug Administration from 2000 to 2015. Primary outcomes were change in 6-min walk distance (6MWD) and World Health Organization (WHO) functional class. RESULTS A total of 5,440 participants from 17 trials were included. Patients with overweight and obesity had lower baseline 6MWD and were more likely to be WHO functional class III or IV. Treatment was associated with a 27.01-m increase in 6MWD (95% CI, 21.58-32.45; P < .001) and lower odds of worse WHO functional class (OR, 0.58; 95% CI, 0.48-0.70; P < .001). For every 1 kg/m2 increase in BMI, 6MWD was reduced by 0.66 m (P = .07); there was no significant effect modification of treatment response in 6MWD according to BMI (P for interaction = .34). Higher BMI was not associated with odds of WHO functional class at end of follow-up; however, higher BMI attenuated the treatment response such that every 1 kg/m2 increase in BMI increased odds of worse WHO functional class by 3% (OR, 1.03; P for interaction = .06). INTERPRETATION Patients with overweight and obesity had lower baseline 6MWD and worse WHO functional class than patients with normal weight with PAH. Higher BMI did not modify the treatment response for change in 6MWD, but it attenuated the treatment response for WHO functional class. PAH trials should include participants representative of all weight groups to allow for assessment of treatment heterogeneity and mechanisms.
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Affiliation(s)
- Breanne E McCarthy
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robyn L McClelland
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA
| | - Dina H Appleby
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jude S Moutchia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jasleen K Minhas
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jeff Min
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - K Akaya Smith
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jason S Fritz
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Steven C Pugliese
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan J Urbanowicz
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John H Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Harold I Palevsky
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Rodriguez-Arias JJ, García-Álvarez A. Sex Differences in Pulmonary Hypertension. FRONTIERS IN AGING 2022; 2:727558. [PMID: 35822006 PMCID: PMC9261364 DOI: 10.3389/fragi.2021.727558] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension (PH) includes multiple diseases that share as common characteristic an elevated pulmonary artery pressure and right ventricular involvement. Sex differences are observed in practically all causes of PH. The most studied type is pulmonary arterial hypertension (PAH) which presents a gender bias regarding its prevalence, prognosis, and response to treatment. Although this disease is more frequent in women, once affected they present a better prognosis compared to men. Even if estrogens seem to be the key to understand these differences, animal models have shown contradictory results leading to the birth of the estrogen paradox. In this review we will summarize the evidence regarding sex differences in experimental animal models and, very specially, in patients suffering from PAH or PH from other etiologies.
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Affiliation(s)
| | - Ana García-Álvarez
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, IDIBAPS, Madrid, Spain.,Universidad de Barcelona, Barcelona, Spain.,Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Cardiovasculares, Madrid, Spain
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Hoeper MM, Pausch C, Olsson KM, Huscher D, Pittrow D, Grünig E, Staehler G, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Park DH, Ewert R, Kaemmerer H, Kabitz HJ, Skowasch D, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H, Claussen M, Lange TJ, Rosenkranz S. COMPERA 2.0: a refined four-stratum risk assessment model for pulmonary arterial hypertension. Eur Respir J 2022. [PMID: 34737226 PMCID: PMC9260123 DOI: 10.1183/13993003.02311-2021,] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). The current European guidelines propose a three-stratum model to categorise risk as low, intermediate or high, based on the expected 1-year mortality. However, with this model, most patients are categorised as intermediate risk. We investigated a modified approach based on four risk categories, with intermediate risk subdivided into intermediate-low and intermediate-high risk. METHODS We analysed data from the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA), a European pulmonary hypertension registry, and calculated risk at diagnosis and first follow-up based on World Health Organization functional class, 6-min walk distance (6MWD) and serum levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP), using refined cut-off values. Survival was assessed using Kaplan-Meier analyses, log-rank testing and Cox proportional hazards models. RESULTS Data from 1655 patients with PAH were analysed. Using the three-stratum model, most patients were classified as intermediate risk (76.0% at baseline and 63.9% at first follow-up). The refined four-stratum risk model yielded a more nuanced separation and predicted long-term survival, especially at follow-up assessment. Changes in risk from baseline to follow-up were observed in 31.1% of the patients with the three-stratum model and in 49.2% with the four-stratum model. These changes, including those between the intermediate-low and intermediate-high strata, were associated with changes in long-term mortality risk. CONCLUSIONS Modified risk stratification using a four-stratum model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically relevant changes in risk than the original three-stratum model.
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Affiliation(s)
- Marius M. Hoeper
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany,German Center of Lung Research (DZL), Germany,Corresponding author: Marius M. Hoeper ()
| | | | - Karen M. Olsson
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany,German Center of Lung Research (DZL), Germany
| | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany,Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- German Center of Lung Research (DZL), Germany,Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Dept of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Dept of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J. Simon R. Gibbs
- Dept of Cardiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven – University of Leuven, Leuven, Belgium
| | - H. Ardeschir Ghofrani
- German Center of Lung Research (DZL), Germany,Dept of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany,Dept of Medicine, Imperial College London, London, UK
| | - Da-Hee Park
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Dept of Respiratory Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für angeborene Herzfehler und Kinderkardiologie, TU München, Munich, Germany
| | - Hans-Joachim Kabitz
- Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Medizinische Klinik II, Konstanz, Germany
| | - Dirk Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik und Poliklinik II, Innere Medizin – Kardiologie/Pneumologie, Bonn, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungenforschungsambulanz, Helmholtz Zentrum, München, Germany,Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Universitätsklinikum Leipzig, Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Leipzig, Germany
| | - Matthias Held
- Dept of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- Attikon University Hospital, 2nd Critical Care Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Dept of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Martin Claussen
- LungenClinic Grosshansdorf, Fachabteilung Pneumologie, Großhansdorf, Germany
| | - Tobias J. Lange
- Dept of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
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Mak S, Kolker S, Girdharry NR, Bentley RF, Valle FH, Gurtu V, Mok KH, Moric J, Thenganatt J, Granton JT. The role of exercise right heart catheterization to guide pulmonary hypertension therapy in older adults. Pulm Circ 2022; 12:e12103. [PMID: 35911185 PMCID: PMC9329818 DOI: 10.1002/pul2.12103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/26/2022] [Accepted: 06/10/2022] [Indexed: 11/26/2022] Open
Abstract
The spectrum of patients referred for suspected pulmonary arterial hypertension (PAH) includes a population with clinical features suggestive of pulmonary hypertension due to left heart disease (PH-LHD). Even after right heart catheterization (RHC) performed at rest, it can be a challenge to identify patients who will clearly benefit from PAH drug therapy. Therefore, the objective of this study was to evaluate the role of exercise RHC to influence decisions regarding prescription of PAH drug therapy in this population. A retrospective cohort study was conducted of older adults with risk factors for PH-LHD and suspected PH referred for exercise RHC. One year follow-up was conducted to record clinical outcomes, all changes in PAH drug therapy, and changes in patient-reported quality of life. The final cohort included 61 patients, mean age of 69 ± 10; 44% and 34% had a history of coronary artery disease and atrial fibrillation respectively. Exercise changed the proportional breakdown of hemodynamic diagnoses from 36% No PH, 44% PAH, and 20% PH-LHD at rest to 15% No PH, 36% PAH, and 49% PH-LHD. Although a significant proportion of patients were reclassified as PH-LHD, there was an overall increase in the proportion of patients receiving PAH drug therapy, particularly for those with PAH confirmed by exercise RHC. A total of 11 PAH drug prescriptions were employed before exercise RHC increasing to 24 after (p = 0.002). Patients receiving PAH therapy demonstrated significant improvement in self-reported quality of life. Exercise RHC appeared to influence selection of PAH drug therapy.
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Affiliation(s)
- Susanna Mak
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
| | | | - Natasha R. Girdharry
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
| | - Robert F. Bentley
- Faculty of Kinesiology and Physical EducationUniversity of TorontoTorontoCanada
| | | | - Vikram Gurtu
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
| | - K. H. Mok
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
| | - Jakov Moric
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
| | - John Thenganatt
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
| | - John T. Granton
- Department of Medicine, Sinai Health/University Health NetworkUniversity of TorontoTorontoCanada
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Peppas S, Nagraj S, Koutsias G, Kladas M, Archontakis-Barakakis P, Schizas D, Giannakoulas G, Palaiodimos L, Kokkinidis DG. Portopulmonary Hypertension: A Review of the Current Literature. Heart Lung Circ 2022; 31:1191-1202. [PMID: 35667970 DOI: 10.1016/j.hlc.2022.04.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/05/2022] [Accepted: 04/21/2022] [Indexed: 12/20/2022]
Abstract
Portopulmonary hypertension is defined as the development of pulmonary arterial hypertension in the setting of portal hypertension with or without liver cirrhosis. Portal hypertension-associated haemodynamic changes, including hyperdynamic state, portosystemic shunts and splanchnic vasodilation, induce significant alterations in pulmonary vascular bed and play a pivotal role in the pathogenesis of the disease. If left untreated, portopulmonary hypertension results in progressive right heart failure, with a poor prognosis. Although Doppler echocardiography is the best initial screening tool for symptomatic patients and liver transplantation candidates, right heart catheterisation remains the gold standard for the diagnosis of the disease. Severe portopulmonary hypertension exerts a prohibitive risk to liver transplantation by conferring an elevated perioperative mortality risk. It is important for haemodynamic parameters to correspond with non-severe portopulmonary hypertension before patients can proceed with the liver transplantation. Small uncontrolled studies and a recent randomised controlled trial have reported promising results with vasodilatory therapies in clinical and haemodynamic improvement of patients, allowing a proportion of patients to undergo liver transplantation. In this review, the epidemiology, pathogenesis, diagnostic approach and management of portopulmonary hypertension are discussed. We also highlight fields of ongoing investigation pertinent to risk stratification and optimal patient selection to maximise long-term benefit from currently available treatments.
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Affiliation(s)
- Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens, Greece.
| | - Sanjana Nagraj
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; Division of Hospital Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - George Koutsias
- Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece
| | - Michail Kladas
- Internal Medicine, North Central Bronx Hospital and James J. Peters VA Medical Center, Bronx, NY, USA
| | | | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leonidas Palaiodimos
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA; Division of Hospital Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
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Cullivan S, Lennon D, Meghani S, Minnock C, McCullagh B, Gaine S. Incidence and outcomes of pulmonary hypertension in the Ireland. BMJ Open Respir Res 2022; 9:9/1/e001272. [PMID: 35768152 PMCID: PMC9244715 DOI: 10.1136/bmjresp-2022-001272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/21/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a progressive disease of the pulmonary vasculature, which is characterised by premature morbidity and mortality. The aim of this study is to define the characteristics of PH in the national PH unit (NPHU) in Ireland between 2010 and 2020. METHODS Cases of PH which were referred to the NPHU between 2010 and 2020 were included. PH was defined as a mean pulmonary artery pressure ≥25 mm Hg at right heart catheterisation. RESULTS Four hundred and fifteen cases of PH were identified during the study period. Group 1 pulmonary arterial hypertension (PAH) accounted for 39% (n=163) of cases, with a calculated annual incidence of 3.11 per million population (95% CI 1.53 to 4.70). The leading PAH subgroup was connective tissue disease-associated PAH (CTD-PAH), which was responsible for 49% of PAH referrals. This was followed by idiopathic PAH, with an estimated annual incidence of 0.63 cases per million population. The mean age at PAH diagnosis was 56±15 years and 86% (n=111) received double-combination or triple-combination therapy within the first 12 months of diagnosis. The 1-year, 3-year and 5-year transplant-free survival for PAH was 89%, 75% and 65%. This was significantly lower for individuals with CTD-PAH relative to other PAH subgroups (p<0.05). DISCUSSION This study describes the incidence and outcomes of PH in Ireland. While the outcomes are comparable to other centres, the incidence of PAH and specific subgroups appears low, suggesting that improved disease awareness and case recognition are required. Furthermore, the survival of individuals with CTD-PAH is poor and requires additional exploration.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Denise Lennon
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Salima Meghani
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Caitriona Minnock
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian McCullagh
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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Hoeper MM, Pausch C, Grünig E, Staehler G, Huscher D, Pittrow D, Olsson KM, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Rosenkranz S, Park DH, Ewert R, Kaemmerer H, Lange TJ, Kabitz HJ, Skowasch D, Skride A, Claussen M, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H. Temporal trends in pulmonary arterial hypertension: results from the COMPERA registry. Eur Respir J 2022; 59:2102024. [PMID: 34675047 PMCID: PMC9160392 DOI: 10.1183/13993003.02024-2021] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Since 2015, the European pulmonary hypertension guidelines recommend the use of combination therapy in most patients with pulmonary arterial hypertension (PAH). However, it is unclear to what extent this treatment strategy is adopted in clinical practice and if it is associated with improved long-term survival. METHODS We analysed data from COMPERA, a large European pulmonary hypertension registry, to assess temporal trends in the use of combination therapy and survival of patients with newly diagnosed PAH between 2010 and 2019. For survival analyses, we looked at annualised data and at cumulated data comparing the periods 2010-2014 and 2015-2019. RESULTS A total of 2531 patients were included. The use of early combination therapy (within 3 months after diagnosis) increased from 10.0% in patients diagnosed with PAH in 2010 to 25.0% in patients diagnosed with PAH in 2019. The proportion of patients receiving combination therapy 1 year after diagnosis increased from 27.7% to 46.3%. When comparing the 2010-2014 and 2015-2019 periods, 1-year survival estimates were similar (89.0% (95% CI 87.2-90.9%) and 90.8% (95% CI 89.3-92.4%), respectively), whereas there was a slight but nonsignificant improvement in 3-year survival estimates (67.8% (95% CI 65.0-70.8%) and 70.5% (95% CI 67.8-73.4%), respectively). CONCLUSIONS The use of combination therapy increased from 2010 to 2019, but most patients still received monotherapy. Survival rates at 1 year after diagnosis did not change over time. Future studies need to determine if the observed trend suggesting improved 3-year survival rates can be confirmed.
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Affiliation(s)
- Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Hannover, Germany
| | | | - Ekkehard Grünig
- Member of the German Center for Lung Research (DZL), Hannover, Germany
- Centre for Pulmonary Hypertension, Thoraxclinic Heidelberg GmbH at Heidelberg University Hospital, Heidelberg, Germany
| | | | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany
- Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Karen M Olsson
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Carmine Dario Vizza
- Dept of Cardiovascular and Respiratory Diseases, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- Member of the German Center for Lung Research (DZL), Hannover, Germany
- Dept of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Dept of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Dept of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J Simon R Gibbs
- Dept of Cardiology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - H Ardeschir Ghofrani
- Member of the German Center for Lung Research (DZL), Hannover, Germany
- Dept of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
- Dept of Medicine, Imperial College London, London, UK
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | - Da-Hee Park
- Dept of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Dept of Respiratory Medicine, Ernst Moritz Arndt University Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für Angeborene Herzfehler und Kinder Kardiologie, TU München, Munich, Germany
| | - Tobias J Lange
- Dept of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Joachim Kabitz
- Medizinische Klinik II, Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Konstanz, Germany
| | - Dirk Skowasch
- Medizinische Klinik und Poliklinik II, Innere Medizin - Kardiologie/Pneumologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Andris Skride
- VSIA Pauls Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Martin Claussen
- Fachabteilung Pneumologie, LungenClinic Grosshansdorf, Grosshansdorf, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungen Forschungsambulanz, Helmholtz Zentrum, Munich, Germany
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Dept of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Matthias Held
- Dept of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- 2nd Critical Care Dept, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Dept of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
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Secular and Regional Trends among Pulmonary Arterial Hypertension Clinical Trial Participants. Ann Am Thorac Soc 2022; 19:952-961. [PMID: 34936541 PMCID: PMC9169130 DOI: 10.1513/annalsats.202110-1139oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: The population of patients with pulmonary arterial hypertension (PAH) has evolved over time from predominantly young White women to an older, more racially diverse and obese population. Whether these changes are reflected in clinical trials is not known. Objectives: To determine secular and regional trends among PAH trial participants. Methods: We performed a pooled cohort analysis using harmonized data from phase III clinical trials of PAH therapies submitted to the U.S. Food and Drug Administration. We used mixed-effects linear and logistic regression to assess regional differences in participant age, sex, body habitus, and hemodynamics over time. Results: A total of 6,599 participants were enrolled in 18 trials between 1998 and 2013; 78% were female. The mean age of participants in North America, Europe, and Latin America at the time of study start increased by 2.09 (95% confidence interval [CI], 0.67-3.51), 1.62 (95% CI, 0.24-3.00), and 4.75 (95% CI, 2.29-7.21) years per 5 years, respectively (P = 0.01). Body mass index at the time of study start increased by 0.72 kg/m2 per 5 years (95% CI, 0.44-0.99; P < 0.001) across all regions. Eighty-five percent of participants in early studies were non-Hispanic White, but this decreased over time to 70%. Ninety-seven percent of Asians and 74% of Hispanics in the sample were recruited from Asia and Latin America. Conclusions: Patients enrolled in more recent PAH therapy trials are older and more obese, mirroring the changing epidemiology of observational cohorts. However, these trends varied by geographic region. PAH cohorts remain predominantly female, presenting challenges for generalizability to male patients. Although the proportion of non-White participants increased over time, this was primarily through recruitment in Asia and Latin America.
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Schuler KP, Hemnes AR, Annis J, Farber-Eger E, Lowery BD, Halliday SJ, Brittain EL. An algorithm to identify cases of pulmonary arterial hypertension from the electronic medical record. Respir Res 2022; 23:138. [PMID: 35643554 PMCID: PMC9145474 DOI: 10.1186/s12931-022-02055-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Study of pulmonary arterial hypertension (PAH) in claims-based (CB) cohorts may facilitate understanding of disease epidemiology, however previous CB algorithms to identify PAH have had limited test characteristics. We hypothesized that machine learning algorithms (MLA) could accurately identify PAH in an CB cohort. METHODS ICD-9/10 codes, CPT codes or PAH medications were used to screen an electronic medical record (EMR) for possible PAH. A subset (Development Cohort) was manually reviewed and adjudicated as PAH or "not PAH" and used to train and test MLAs. A second subset (Refinement Cohort) was manually reviewed and combined with the Development Cohort to make The Final Cohort, again divided into training and testing sets, with MLA characteristics defined on test set. The MLA was validated using an independent EMR cohort. RESULTS 194 PAH and 786 "not PAH" in the Development Cohort trained and tested the initial MLA. In the Final Cohort test set, the final MLA sensitivity was 0.88, specificity was 0.93, positive predictive value was 0.89, and negative predictive value was 0.92. Persistence and strength of PAH medication use and CPT code for right heart catheterization were principal MLA features. Applying the MLA to the EMR cohort using a split cohort internal validation approach, we found 265 additional non-confirmed cases of suspected PAH that exhibited typical PAH demographics, comorbidities, hemodynamics. CONCLUSIONS We developed and validated a MLA using only CB features that identified PAH in the EMR with strong test characteristics. When deployed across an entire EMR, the MLA identified cases with known features of PAH.
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Affiliation(s)
- Kyle P Schuler
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey Annis
- Division of Cardiovascular Medicine, Vanderbilt Pulmonary Circulation Center, 2525 West End Avenue, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Nashville, TN, USA
| | - Eric Farber-Eger
- Division of Cardiovascular Medicine, Vanderbilt Pulmonary Circulation Center, 2525 West End Avenue, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Nashville, TN, USA
| | - Brandon D Lowery
- Division of Cardiovascular Medicine, Vanderbilt Pulmonary Circulation Center, 2525 West End Avenue, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Nashville, TN, USA
| | - Stephen J Halliday
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Vanderbilt Pulmonary Circulation Center, 2525 West End Avenue, Nashville, TN, USA.
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Kostura M, Smalley C, Koyfman A, Long B. Right heart failure: A narrative review for emergency clinicians. Am J Emerg Med 2022; 58:106-113. [PMID: 35660367 DOI: 10.1016/j.ajem.2022.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Right heart failure (RHF) is a clinical syndrome with impaired right ventricular cardiac output due to a variety of etiologies including ischemia, elevated pulmonary arterial pressure, or volume overload. Emergency department (ED) patients with an acute RHF exacerbation can be diagnostically and therapeutically challenging to manage. OBJECTIVE This narrative review describes the pathophysiology of right ventricular dysfunction and pulmonary hypertension, the methods to diagnose RHF in the ED, and management strategies. DISCUSSION Right ventricular contraction normally occurs against a low pressure, highly compliant pulmonary vascular system. This physiology makes the right ventricle susceptible to acute changes in afterload, which can lead to RHF. Patients with acute RHF may present with an acute illness and have underlying chronic pulmonary hypertension due to left ventricular failure, pulmonary arterial hypertension, chronic lung conditions, thromboemboli, or idiopathic conditions. Patients can present with a variety of symptoms resulting from systemic edema and hemodynamic compromise. Evaluation with electrocardiogram, laboratory analysis, and imaging is necessary to evaluate cardiac function and end organ injury. Management focuses on treating the underlying condition, optimizing oxygenation and ventilation, treating arrhythmias, and understanding the patient's hemodynamics with bedside ultrasound. As RHF patients are preload dependent they may require fluid resuscitation or diuresis. Hypotension should be rapidly addressed with vasopressors. Cardiac contractility can be augmented with inotropes. Efforts should be made to support oxygenation while trying to avoid intubation if possible. CONCLUSIONS Emergency clinician understanding of this condition is important to diagnose and treat this life-threatening cardiopulmonary disorder.
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Affiliation(s)
- Matthew Kostura
- Department of Emergency Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Courtney Smalley
- Department of Emergency Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Role of curcumin in ameliorating hypertension and associated conditions: a mechanistic insight. Mol Cell Biochem 2022; 477:2359-2385. [DOI: 10.1007/s11010-022-04447-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 04/24/2022] [Indexed: 12/23/2022]
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Tsujimoto Y, Kumasawa J, Shimizu S, Nakano Y, Kataoka Y, Tsujimoto H, Kono M, Okabayashi S, Imura H, Mizuta T. Doppler trans-thoracic echocardiography for detection of pulmonary hypertension in adults. Cochrane Database Syst Rev 2022; 5:CD012809. [PMID: 35532166 PMCID: PMC9132178 DOI: 10.1002/14651858.cd012809.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is an important cause of morbidity and mortality, which leads to a substantial loss of exercise capacity. PH ultimately leads to right ventricular overload and subsequent heart failure and early death. Although early detection and treatment of PH are recommended, due to the limited responsiveness to therapy at late disease stages, many patients are diagnosed at a later stage of the disease because symptoms and signs of PH are nonspecific at earlier stages. While direct pressure measurement with right-heart catheterisation is the clinical reference standard for PH, it is not routinely used due to its invasiveness and complications. Trans-thoracic Doppler echocardiography is less invasive, less expensive, and widely available compared to right-heart catheterisation; it is therefore recommended that echocardiography be used as an initial diagnosis method in guidelines. However, several studies have questioned the accuracy of noninvasively measured pulmonary artery pressure. There is substantial uncertainty about the diagnostic accuracy of echocardiography for the diagnosis of PH. OBJECTIVES To determine the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH. SEARCH METHODS We searched MEDLINE, Embase, Web of Science Core Collection, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform from database inception to August 2021, reference lists of articles, and contacted study authors. We applied no restrictions on language or type of publication. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of trans-thoracic Doppler echocardiography for detecting PH, where right-heart catheterisation was the reference standard. We excluded diagnostic case-control studies (two-gate design), studies where right-heart catheterisation was not the reference standard, and those in which the reference standard threshold differed from 25 mmHg. We also excluded studies that did not provide sufficient diagnostic test accuracy data (true-positive [TP], false-positive [FP], true-negative [TN], and false-negative [FN] values, based on the reference standard). We included studies that provided data from which we could extract TP, FP, TN, and FN values, based on the reference standard. Two authors independently screened and assessed the eligibility based on the titles and abstracts of records identified by the search. After the title and abstract screening, the full-text reports of all potentially eligible studies were obtained, and two authors independently assessed the eligibility of the full-text reports. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. We assessed the methodological quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. We estimated a summary receiver operating characteristic (SROC) curve by fitting a hierarchical summary ROC (HSROC) non-linear mixed model. We explored sources of heterogeneity regarding types of PH, methods to estimate the right atrial pressure, and threshold of index test to diagnose PH. All analyses were performed using the Review Manager 5, SAS and STATA statistical software. MAIN RESULTS We included 17 studies (comprising 3656 adult patients) assessing the diagnostic accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH. The included studies were heterogeneous in terms of patient distribution of age, sex, WHO classification, setting, country, positivity threshold, and year of publication. The prevalence of PH reported in the included studies varied widely (from 6% to 88%). The threshold of index test for PH diagnosis varied widely (from 30 mmHg to 47 mmHg) and was not always prespecified. No study was assigned low risk of bias or low concern in each QUADAS-2 domain assessed. Poor reporting, especially in the index test and reference standard domains, hampered conclusive judgement about the risk of bias. There was little consistency in the thresholds used in the included studies; therefore, common thresholds contained very sparse data, which prevented us from calculating summary points of accuracy estimates. With a fixed specificity of 86% (the median specificity), the estimated sensitivity derived from the median value of specificity using HSROC model was 87% (95% confidence interval [CI]: 78% to 96%). Using a prevalence of PH of 68%, which was the median among the included studies conducted mainly in tertiary hospitals, diagnosing a cohort of 1000 adult patients under suspicion of PH would result in 88 patients being undiagnosed with PH (false negatives) and 275 patients would avoid unnecessary referral for a right-heart catheterisation (true negatives). In addition, 592 of 1000 patients would receive an appropriate and timely referral for a right-heart catheterisation (true positives), while 45 patients would be wrongly considered to have PH (false positives). Conversely, when we assumed low prevalence of PH (10%), as in the case of preoperative examinations for liver transplantation, the number of false negatives and false positives would be 13 and 126, respectively. AUTHORS' CONCLUSIONS Our evidence assessment of echocardiography for the diagnosis of PH in adult patients revealed several limitations. We were unable to determine the average sensitivity and specificity at any particular index test threshold and to explain the observed variability in results. The high heterogeneity of the collected data and the poor methodological quality would constrain the implementation of this result into clinical practice. Further studies relative to the accuracy of Doppler trans-thoracic echocardiography for the diagnosis of PH in adults, that apply a rigorous methodology for conducting diagnostic test accuracy studies, are needed.
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Affiliation(s)
- Yasushi Tsujimoto
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Kawanishi, Japan
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Department of Clinical Research and Epidemiology, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshio Nakano
- Department of Respiratory Medicine, Sakai City Medical Center, Sakai City, Japan
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Michihiko Kono
- Department of Critical Care Medicine, Sakai City Medical Center, Osaka, Japan
| | - Shinji Okabayashi
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruki Imura
- Department of Health Informatics, School of Public Health in Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Mizuta
- Department of Dermatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Kianzad A, van Wezenbeek J, Celant LR, Oosterveer FP, Noordegraaf AV, Meijboom LJ, de Man FS, Bogaard HJ, Handoko ML. Idiopathic pulmonary arterial hypertension patients with a high H2FPEF-score: insights from the Amsterdam UMC PAH-cohort. J Heart Lung Transplant 2022; 41:1075-1085. [DOI: 10.1016/j.healun.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 04/19/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022] Open
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Proteasome Inhibitors Decrease the Viability of Pulmonary Arterial Smooth Muscle Cells by Restoring Mitofusin-2 Expression under Hypoxic Conditions. Biomedicines 2022; 10:biomedicines10040873. [PMID: 35453623 PMCID: PMC9030547 DOI: 10.3390/biomedicines10040873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 02/04/2023] Open
Abstract
Pulmonary hypertension (PH) is a severe progressive disease, and the uncontrolled proliferation of pulmonary artery smooth muscle cells (PASMCs) is one of the main causes. Mitofusin-2 (MFN2) profoundly inhibits cell growth and proliferation in a variety of tumor cell lines and rat vascular smooth muscle cells. Down-regulation of MFN2 is known to contribute to PH. Proteasome inhibitors have been shown to inhibit the proliferation of PASMCs; however, there is no study on the regulation of proteasome inhibitors through MFN-2 in the proliferation of PASMCs, a main pathophysiology of PH. In this study, PASMCs were exposed to hypoxic conditions and the expression of MFN2 and cleaved-PARP1 were detected by Western blotting. The effects of hypoxia and proteasome inhibitors on the cell viability of PASMC cells were detected by CCK8 assay. The results indicated that hypoxia increases the viability and reduces the expression of MFN2 in a PASMCs model. MFN2 overexpression inhibits the hypoxia-induced proliferation of PASMCs. In addition, proteasome inhibitors, bortezomib and marizomib, restored the decreased expression of MFN2 under hypoxic conditions, inhibited hypoxia-induced proliferation and induced the expression of cleaved-PARP1. These results suggest that bortezomib and marizomib have the potential to improve the hypoxia-induced proliferation of PASMCs by restoring MFN2 expression.
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Yang JZ, Odish MF, Mathers H, Pebley N, Wardi G, Papamatheakis DG, Poch DS, Kim NH, Fernandes TM, Sell RE. Outcomes of Cardiopulmonary Resuscitation in Patients with Pulmonary Arterial Hypertension. Pulm Circ 2022; 12:e12066. [PMID: 35514777 PMCID: PMC9063951 DOI: 10.1002/pul2.12066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jenny Z. Yang
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Mazen F. Odish
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Hannah Mathers
- School of Medicine. University of California San DiegoLa Jolla92037
| | - Nicole Pebley
- School of Medicine. University of California San DiegoLa Jolla92037
| | - Gabriel Wardi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Demosthenes G. Papamatheakis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - David S. Poch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Nick H. Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Timothy M. Fernandes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Rebecca E. Sell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
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Abstract
Pulmonary hypertension is an enigmatic, deleterious disease driven by multiple heterogeneous causes with a burgeoning proportion of older patients with complex, chronic comorbidities without adequate treatment options. The underlying endothelial pathophenotypes that direct vasoconstriction and panvascular remodeling remain both controversial and incompletely defined. This review discusses emerging concepts centered on endothelial senescence in pulmonary vascular disease. This principle proposes a more heterogeneous, dynamic pulmonary endothelium in disease; it provides a potentially unifying feature of endothelial dysfunction in pulmonary hypertension irrespective of cause; and it supports a clinically relevant link between aging and pulmonary hypertension like other chronic illnesses. Thus, taking cues from studies on aging and age-related diseases, we present possible opportunities and barriers to diagnostic and therapeutic targeting of senescence in pulmonary hypertension.
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Affiliation(s)
- Miranda K Culley
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, PA
| | - Stephen Y Chan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, PA
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Appenzeller P, Gautschi F, Müller J, Lichtblau M, Saxer S, Schneider SR, Schwarz EI, Ulrich S. Prediction of peak oxygen uptake from 6-minute walk test in pulmonary hypertension. ERJ Open Res 2022; 8:00664-2021. [PMID: 35747228 PMCID: PMC9209853 DOI: 10.1183/23120541.00664-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/16/2022] [Indexed: 11/06/2022] Open
Abstract
Maximal oxygen uptake (V′O2max), assessed by cardiopulmonary exercise testing (CPET), is an important parameter for risk assessment in patients with pulmonary hypertension (PH). However, CPET may not be available for all PH patients. Thus, we aimed to test previously published predictive models of V′O2max from the 6-min walk distance (6MWD) for their accuracy and to create a new model. We tested four models (two by Ross et al. (2010), one by Miyamoto et al. (2000) and one by Zapico et al. (2019)). To derive a new model, data were split into a training and testing dataset (70:30) and step-wise linear regression was performed. To compare the different models, the standard error of the estimate (SEE) was calculated and the models graphically compared by Bland–Altman plots. Sensitivity and specificity for correct prediction into low-risk classification (V′O2max >15 mL/min/kg) was calculated for all models. A total of 276 observations were included in the analysis (194/82 training/testing dataset); 6MWD and V′O2max were significantly correlated (r=0.65, p<0.001). Linear regression showed significant correlation of 6MWD, weight and heart rate response (HRR) with V′O2max and the best fitting prediction equation was: V′O2max = 1.83 + 0.031 × 6MWD (m) – 0.023 × weight (kg) – 0.015 × HRR (bpm). SEEs for the different models were 3.03, 3.22, 4.36 and 3.08 mL/min/kg for the Ross et al., Miyamoto et al., Zapico et al. models and the new model, respectively. Predicted mean V′O2max was 16.5 mL/min/kg (versus observed 16.1 mL/min/kg). 6MWD and V′O2max reveal good correlation in all models. However, the accuracy of all models is inadequate for clinical use. Thus, CPET and 6MWD both remain valuable risk assessment tools in the management of PH. Although maximal oxygen uptake and the 6-min walk distance show good correlation in pulmonary hypertension, all predictive models are of inadequate accuracy for clinical use and cardiopulmonary exercise testing remains an irreplaceable toolhttps://bit.ly/33HBQFk
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Important Functions and Molecular Mechanisms of Mitochondrial Redox Signaling in Pulmonary Hypertension. Antioxidants (Basel) 2022; 11:antiox11030473. [PMID: 35326123 PMCID: PMC8944689 DOI: 10.3390/antiox11030473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 12/13/2022] Open
Abstract
Mitochondria are important organelles that act as a primary site to produce reactive oxygen species (ROS). Additionally, mitochondria play a pivotal role in the regulation of Ca2+ signaling, fatty acid oxidation, and ketone synthesis. Dysfunction of these signaling molecules leads to the development of pulmonary hypertension (PH), atherosclerosis, and other vascular diseases. Features of PH include vasoconstriction and pulmonary artery (PA) remodeling, which can result from abnormal proliferation, apoptosis, and migration of PA smooth muscle cells (PASMCs). These responses are mediated by increased Rieske iron–sulfur protein (RISP)-dependent mitochondrial ROS production and increased mitochondrial Ca2+ levels. Mitochondrial ROS and Ca2+ can both synergistically activate nuclear factor κB (NF-κB) to trigger inflammatory responses leading to PH, right ventricular failure, and death. Evidence suggests that increased mitochondrial ROS and Ca2+ signaling leads to abnormal synthesis of ketones, which play a critical role in the development of PH. In this review, we discuss some of the recent findings on the important interactive role and molecular mechanisms of mitochondrial ROS and Ca2+ in the development and progression of PH. We also address the contributions of NF-κB-dependent inflammatory responses and ketone-mediated oxidative stress due to abnormal regulation of mitochondrial ROS and Ca2+ signaling in PH.
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71
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Bazan IS, Ardito TA, Zhang Y, Shan P, Kim SJ, Sauler M, Lee P. Sex Differences and Altered Mitophagy in Experimental Pulmonary Hypertension. Am J Physiol Lung Cell Mol Physiol 2022; 322:L761-L769. [PMID: 35137625 PMCID: PMC9076415 DOI: 10.1152/ajplung.00019.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension (PH) is a debilitating condition characterized by increased pulmonary arterial pressures and remodeling of pulmonary arteries, leading to right heart failure. Women have a higher prevalence of PH, while men have more severe disease and poorer outcomes. Animal models also show a female-predominant disease. Despite the known sex differences in PH, little is known about how the pathogenesis differs between the sexes. There is growing evidence of mitochondrial dysfunction in PH, as well as suggestions of altered mitophagy. We hypothesized that sexual dimorphism contributes to mitochondrial dysfunction and altered mitophagy in PH. Using mouse lung endothelial cells (MLECs), we exposed both wild-type and Parkin -/- cells to hypoxia and measured the effects on mitochondrial function and mitophagy-associated proteins. Our results show that females have more Parkin expression and increased mitochondrial respiratory capacity when exposed to oxidative stress. Inhibition of Parkin increased metabolic activity in but reduced cell proliferation, with results differing by sex. Our findings demonstrate sexual dimorphism in mitophagy-associated proteins and in mitochondrial respiration, which may help shed light on how the pathogenesis of PH may differ between the sexes.
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Affiliation(s)
- Isabel S Bazan
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, United States
| | - Taylor A Ardito
- Duke University, Section of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, United States
| | - Yi Zhang
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, United States
| | - Peiying Shan
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, United States
| | - So-Jin Kim
- Duke University, Section of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, United States
| | - Maor Sauler
- Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, United States
| | - Patty Lee
- Duke University, Section of Pulmonary, Allergy, and Critical Care Medicine, Durham, NC, United States
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Wijeratne DT, Housin A, Lajkosz K, Lougheed MD, Yu Xiong P, Barber D, Doliszny KM, Archer SL. Validating Health Administrative data to Identify Patients with Pulmonary HypertensionUsing Health Administrative data to Identify Patients with Pulmonary Hypertension:
A single center, proof of concept validation study in Ontario, Canada. Pulm Circ 2022; 12:e12040. [PMID: 35506095 PMCID: PMC9052993 DOI: 10.1002/pul2.12040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/16/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Don Thiwanka Wijeratne
- Department of Medicine Queen's University, Kingston Ontario, Canada
- Institute for Clinical Evaluative Sciences Queen's, Queen's University, Kingston Ontario
| | - Ahmad Housin
- Department of Medicine Queen's University, Kingston Ontario, Canada
| | - Katherine Lajkosz
- Institute for Clinical Evaluative Sciences Queen's, Queen's University, Kingston Ontario
| | - M. Diane Lougheed
- Department of Medicine Queen's University, Kingston Ontario, Canada
- Institute for Clinical Evaluative Sciences Queen's, Queen's University, Kingston Ontario
- Department of Public Health Sciences Queen's University, Kingston Ontario, Canada
| | - Ping Yu Xiong
- Department of Medicine Queen's University, Kingston Ontario, Canada
| | - David Barber
- Department of Medicine Queen's University, Kingston Ontario, Canada
| | | | - Stephen L Archer
- Department of Medicine Queen's University, Kingston Ontario, Canada
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Emmons‐Bell S, Johnson C, Boon‐Dooley A, Corris PA, Leary PJ, Rich S, Yacoub M, Roth GA. Prevalence, incidence, and survival of pulmonary arterial hypertension: A systematic review for the global burden of disease 2020 study. Pulm Circ 2022; 12:e12020. [PMID: 35506069 PMCID: PMC9052982 DOI: 10.1002/pul2.12020] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/13/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized by increased resistance in the pulmonary arterioles as a result of remodeled blood vessels. We sought all available epidemiologic data on population‐based prevalence, incidence, and 1‐year survival of PAH as part of the Global Burden of Disease Study. We performed a systematic review searching Global Index Medicus (GIM) for keywords related to PAH between 1980 and 2021 and identified population‐representative sources of prevalence, incidence, and mortality for clinically diagnosed PAH. Of 6772 articles identified we found 65 with population‐level data: 17 for prevalence, 17 for incidence, and 58 reporting case fatality. Reported prevalence ranged from 0.37 cases/100,000 persons in a referral center of French children to 15 cases/100,000 persons in an Australian study. Reported incidence ranged from 0.008 cases/100,000 person‐years in Finland, to 1.4 cases/100,000 person‐years in a retrospective chart review at a clinic in Utah, United States. Reported 1‐year survival ranged from 67% to 99%. All studies with sex‐specific estimates of prevalence or incidence reported higher levels in females than males. Studies varied in their size, study design, diagnostic criteria, and sampling procedures. Reported PAH prevalence, incidence, and mortality varied by location and study. Prevalence ranged from 0.4 to 1.4 per 100,000 persons. Harmonization of methods for PAH registries would improve efforts at disease surveillance. Results of this search contribute to ongoing efforts to quantify the global burden of PAH.
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Affiliation(s)
- Sophia Emmons‐Bell
- Institute for Health Metrics and Evaluation University of Washington Seattle Washington USA
| | - Catherine Johnson
- Institute for Health Metrics and Evaluation University of Washington Seattle Washington USA
| | - Alexandra Boon‐Dooley
- Institute for Health Metrics and Evaluation University of Washington Seattle Washington USA
| | - Paul A. Corris
- Translational and Clinical Research Institute, Faculty of Medical Sciences Newcastle University Newcastle upon Tyne UK
- Pulmonary Vascular Research Institute UK
| | - Peter J. Leary
- Division of Pulmonary, Critical Care, and Sleep Medicine University of Washington Seattle Washington USA
| | - Stuart Rich
- Division of Cardiology Northwestern Memorial Hospital Chicago Illinois USA
| | - Magdi Yacoub
- Aswan Heart Centre Aswan Egypt
- National Heart & Lung Institute Imperial College London London UK
- Harefield Heart Science Centre London UK
| | - Gregory A. Roth
- Institute for Health Metrics and Evaluation University of Washington Seattle Washington USA
- Division of Cardiology, Department of Medicine University of Washington Seattle Washington USA
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74
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Torbic H, Hohlfelder B, Krishnan S, Tonelli AR. A Review of Pulmonary Arterial Hypertension Treatment in Extracorporeal Membrane Oxygenation: A Case Series of Adult Patients. J Cardiovasc Pharmacol Ther 2022; 27:10742484211069005. [PMID: 35006031 DOI: 10.1177/10742484211069005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little data is published describing the use of medications prescribed for pulmonary arterial hypertension (PAH) in patients receiving extracorporeal membrane oxygenation (ECMO). Even though many patients with PAH may require ECMO as a bridge to transplant or recovery, little is reported regarding the use of PAH medications in this setting. METHODS This retrospective case series summarizes the clinical experience of 8 patients with PAH receiving ECMO and reviews medication management in the setting of ECMO. RESULTS Eight PAH patients, 5 of whom were female, ranging in age from 21 to 61 years old, were initiated on ECMO. Veno-arterial (VA) ECMO was used in 4 patients, veno-venous (VV) ECMO and hybrid ECMO configurations in 2 patients respectively. Common indications for ECMO included cardiogenic shock, bridge to transplant, and cardiac arrest. All patients were on intravenous (IV) prostacyclin therapy at baseline. Refractory hypotension was noted in 7 patients of whom 5 patients required downtitration or discontinuation of baseline PAH therapies. Three patients had continuous inhaled epoprostenol added during their time on ECMO. In patients who were decannulated from ECMO, PAH therapies were typically resumed or titrated back to baseline dosages. One patient required no adjustment in PAH therapy while on ECMO. Two patients were not able to be decannulated from ECMO. CONCLUSION The treatment of critically ill PAH patients is challenging given a variety of factors that could affect PAH drug concentrations. In particular, PAH patients on prostacyclin analogues placed on VA ECMO appear to have pronounced systemic vasodilation requiring vasopressors which is alleviated by temporarily reducing the intravenous prostacyclin dose. Patients should be closely monitored for potential need for rapid titrations in prostacyclin therapy to maintain hemodynamic stability.
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Affiliation(s)
- Heather Torbic
- 2569Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sudhir Krishnan
- Department of Critical Care Medicine, 2569Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, 2569Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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75
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Sharifi Kia D, Shen Y, Bachman TN, Goncharova EA, Kim K, Simon MA. The Effects of Healthy Aging on Right Ventricular Structure and Biomechanical Properties: A Pilot Study. Front Med (Lausanne) 2022; 8:751338. [PMID: 35083230 PMCID: PMC8784691 DOI: 10.3389/fmed.2021.751338] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Healthy aging has been associated with alterations in pulmonary vascular and right ventricular (RV) hemodynamics, potentially leading to RV remodeling. Despite the current evidence suggesting an association between aging and alterations in RV function and higher prevalence of pulmonary hypertension in the elderly, limited data exist on age-related differences in RV structure and biomechanics. In this work, we report our preliminary findings on the effects of healthy aging on RV structure, function, and biomechanical properties. Hemodynamic measurements, biaxial mechanical testing, constitutive modeling, and quantitative transmural histological analysis were employed to study two groups of male Sprague-Dawley rats: control (11 weeks) and aging (80 weeks). Aging was associated with increases in RV peak pressures (+17%, p = 0.017), RV contractility (+52%, p = 0.004), and RV wall thickness (+38%, p = 0.001). Longitudinal realignment of RV collagen (16.4°, p = 0.013) and myofibers (14.6°, p = 0.017) were observed with aging, accompanied by transmural cardiomyocyte loss and fibrosis. Aging led to increased RV myofiber stiffness (+141%, p = 0.003), in addition to a bimodal alteration in the biaxial biomechanical properties of the RV free wall, resulting in increased tissue-level stiffness in the low-strain region, while progressing into decreased stiffness at higher strains. Our results demonstrate that healthy aging may modulate RV remodeling via increased peak pressures, cardiomyocyte loss, fibrosis, fiber reorientation, and altered mechanical properties in male Sprague-Dawley rats. Similarities were observed between aging-induced remodeling patterns and those of RV remodeling in pressure overload. These findings may help our understanding of age-related changes in the cardiovascular fitness and response to disease.
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Affiliation(s)
- Danial Sharifi Kia
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yuanjun Shen
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Davis School of Medicine Lung Center, University of California, Davis, Davis, CA, United States
| | - Timothy N. Bachman
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Elena A. Goncharova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Davis School of Medicine Lung Center, University of California, Davis, Davis, CA, United States
- Division of Pulmonary, Allergy and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kang Kim
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Division of Cardiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Ultrasound Molecular Imaging and Therapeutics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Marc A. Simon
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Appenzeller P, Lichtblau M, Berlier C, Aubert J, Azzola A, Fellrath J, Geiser T, Lador F, Pohle S, Opitz I, Schwerzmann M, Stricker H, Tamm M, Saxer S, Ulrich S. Disease characteristics and clinical outcome over two decades from the Swiss pulmonary hypertension registry. Pulm Circ 2022; 12:e12001. [DOI: 10.1002/pul2.12001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 09/28/2021] [Accepted: 11/06/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Paula Appenzeller
- Clinic of Pulmonology, University Hospital Zurich Zurich Switzerland
| | - Mona Lichtblau
- Clinic of Pulmonology, University Hospital Zurich Zurich Switzerland
| | - Charlotte Berlier
- Clinic of Pulmonology, University Hospital Zurich Zurich Switzerland
| | | | - Andrea Azzola
- Center of Pulmonology, Cantonal Hospital Lucerne Lucerne Switzerland
| | - Jean‐Marc Fellrath
- Center of Pulmonology, Hôpital neuchâtelois Pourtalès Neuenburg Switzerland
| | - Thomas Geiser
- Interdisciplinary Center for Pulmonary Hypertension, Bern University Hospital and University of Bern Bern Switzerland
| | - Frederic Lador
- Pulmonary Hypertension Program, University Hospital of Geneva Geneva Switzerland
| | - Susanne Pohle
- Lung Center, Cantonal Hospital St. Gallen St. Gallen Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery University Hospital Zurich Zurich Switzerland
| | - Markus Schwerzmann
- Interdisciplinary Center for Pulmonary Hypertension, Bern University Hospital and University of Bern Bern Switzerland
| | - Hans Stricker
- Department of Angiology Ospedale La Carità Locarno Switzerland
| | - Michael Tamm
- Center of Pulmonology, University Hospital Basel Basel Switzerland
| | - Stéphanie Saxer
- Clinic of Pulmonology, University Hospital Zurich Zurich Switzerland
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital Zurich Zurich Switzerland
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Yokose M, Tomoe T, Yamaguchi T, Yasu T. An autopsy case of pulmonary arterial hypertension in an elderly patient with multimorbidity: a case report. Eur Heart J Case Rep 2022; 6:ytab527. [PMID: 35028503 PMCID: PMC8753136 DOI: 10.1093/ehjcr/ytab527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 12/22/2021] [Indexed: 11/12/2022]
Abstract
Abstract
Background
There is an increasing number of elderly patients with pulmonary arterial hypertension (PAH), and their characteristics differ from those of young or middle-aged patients with this condition.
Case summary
A 73-year-old woman with a history of myocardial infarction and cardiovascular risk factors was admitted to the hospital with 2-week exertional dyspnoea. Her initial diagnosis was heart failure with preserved ejection fraction, but the symptoms persisted despite receiving treatment with diuretics. Additional tests showed a significant decrease in diffusing capacity of carbon monoxide and findings suggestive of severe pulmonary hypertension (PH). Contrast-enhanced computed tomography of the chest, and pulmonary angiography, showed no narrowing or obstruction of the pulmonary arteries. Right heart catheterization revealed haemodynamic data implying pre-capillary PH. Her condition gradually deteriorated to World Health Organization functional class IV, and sequential combination therapy with tadalafil, macitentan, and selexipag was initiated with a PAH diagnosis; however, she died 1 month later. Pathological findings in autopsy were consistent with PAH, and some parts of the lungs revealed the presence of obstructive and interstitial lung disease.
Discussion
The majority of elderly patients with PAH might have multimorbidity. However, there is no specific treatment strategy. It is associated with diagnostic delay and worse prognosis; therefore, early suspicion and comprehensive tests, including right heart catheterization, are essential for better management.
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Affiliation(s)
- Masashi Yokose
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| | - Takashi Tomoe
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| | - Takehiko Yamaguchi
- Department of Pathology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
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78
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Moutsoglou DM. 2021 American Thoracic Society BEAR Cage Winning Proposal: Microbiome Transplant in Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2022; 205:13-16. [PMID: 34758276 PMCID: PMC8865595 DOI: 10.1164/rccm.202108-1833ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Wardle M, Nair A, Saunders S, Armstrong I, Charalampopoulos A, Elliot C, Hameed A, Hamilton N, Harrington J, Keen C, Lewis R, Sabroe I, Thompson AAR, Kerry RM, Condliffe R, Kiely DG. Elective lower limb orthopedic arthroplasty surgery in patients with pulmonary hypertension. Pulm Circ 2022; 12:e12019. [PMID: 35506074 PMCID: PMC9053006 DOI: 10.1002/pul2.12019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/14/2021] [Accepted: 10/30/2021] [Indexed: 11/08/2022] Open
Abstract
Patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (PH) are at increased risk when undergoing anesthesia and major surgery. Data on outcomes for elective orthopedic surgery in patients with PH are limited. A patient pathway was established to provide access to elective lower limb arthroplasty. This included assessment of orthopedic needs, fitness for anesthesia, preoperative optimization, and intra- and postoperative management. Patient data were retrospectively retrieved using patient's hospital records. Between 2012 and 2020, 29 operations (21 total hip replacements [THRs], 7 total knee replacements [TKRs], 1 total hip revision) were performed in 25 patients (mean age: 67 years). Perioperatively, 72% were treated with low-dose intravenous prostanoid. All had arterial lines, and central access and perioperative lithium dilution cardiac output monitoring was used in 86% of cases. Four patients underwent GA, 21 spinal anesthesia, and 4 CSE anesthesia. Supplemental nerve blocks were performed in all patients undergoing general, and 12 of 21 undergoing spinal anesthesia. All were managed in high dependency postoperatively. Hospital length of stay and complication rates were higher than reported in non-PH patients. Perioperative complications included hypotension requiring vasopressors (n = 10), blood transfusion (n = 7), nonorthopedic infection (n = 4), and decompensated right heart failure (n = 1). There was no associated mortality. All implants were functioning well at 6 weeks and subsequent follow-up. EmPHasis-10 quality of score decreased by 5.5 (±2.1) (p = 0.04). A dedicated multiprofessional pathway can be used to safely select and manage patients with PH through elective lower limb arthroplasty.
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Affiliation(s)
- Mikaela Wardle
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK.,Department of Anaesthetics Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Amanda Nair
- Department of Anaesthetics Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Sarah Saunders
- Department of Anaesthetics Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Iain Armstrong
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | | | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK.,Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield UK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - John Harrington
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Carol Keen
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK.,Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield UK
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK.,Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield UK
| | - Robert M Kerry
- Department of Orthopaedic Surgery Sheffield Teaching Hospitals NHS Trust Sheffield UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK.,Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit Sheffield Teaching Hospitals NHS Trust Sheffield UK.,Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield UK
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Cabral DR, Guimarães T, Almeida AG, Campos P, Martins SR, da Silva PC, Pinto FJ, Plácido R. Chest pain in a patient with pulmonary arterial hypertension. Rev Port Cardiol 2022; 41:73-80. [DOI: 10.1016/j.repc.2020.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/18/2020] [Accepted: 05/05/2020] [Indexed: 10/20/2022] Open
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81
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Cheron C, McBride SA, Antigny F, Girerd B, Chouchana M, Chaumais MC, Jaïs X, Bertoletti L, Sitbon O, Weatherald J, Humbert M, Montani D. Sex and gender in pulmonary arterial hypertension. Eur Respir Rev 2021; 30:30/162/200330. [PMID: 34750113 DOI: 10.1183/16000617.0330-2020] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/28/2021] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease characterised by pulmonary vascular remodelling and elevated pulmonary pressure, which eventually leads to right heart failure and death. Registries worldwide have noted a female predominance of the disease, spurring particular interest in hormonal involvement in the disease pathobiology. Several experimental models have shown both protective and deleterious effects of oestrogens, suggesting that complex mechanisms participate in PAH pathogenesis. In fact, oestrogen metabolites as well as receptors and enzymes implicated in oestrogen signalling pathways and associated conditions such as BMPR2 mutation contribute to PAH penetrance more specifically in women. Conversely, females have better right ventricular function, translating to a better prognosis. Along with right ventricular adaptation, women tend to respond to PAH treatment differently from men. As some young women suffer from PAH, contraception is of particular importance, considering that pregnancy in patients with PAH is strongly discouraged due to high risk of death. When contraception measures fail, pregnant women need a multidisciplinary team-based approach. This article aims to review epidemiology, mechanisms underlying the higher female predominance, but better prognosis and the intricacies in management of women affected by PAH.
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Affiliation(s)
- Céline Cheron
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Susan Ainslie McBride
- Internal Medicine Residency Program, Dept of Medicine, University of Calgary, Calgary, Canada
| | - Fabrice Antigny
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Barbara Girerd
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Margot Chouchana
- Assistance Publique Hôpitaux de Paris, Service de Pharmacie Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Marie-Camille Chaumais
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France.,Assistance Publique Hôpitaux de Paris, Service de Pharmacie Hôpital Bicêtre, Le Kremlin Bicêtre, France.,Université Paris-Saclay, Faculté de Pharmacie, Chatenay Malabry, France
| | - Xavier Jaïs
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Laurent Bertoletti
- Centre Hospitalier Universitaire de Saint-Etienne, Service de Médecine Vasculaire et Thérapeutique, Saint-Etienne, France.,INSERM U1059 et CIC1408, Université Jean-Monnet, Saint-Etienne, France
| | - Olivier Sitbon
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Jason Weatherald
- Division of Respirology, Dept of Medicine, University of Calgary, Calgary, Canada.,Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - David Montani
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France .,Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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Biological heterogeneity in idiopathic pulmonary arterial hypertension identified through unsupervised transcriptomic profiling of whole blood. Nat Commun 2021; 12:7104. [PMID: 34876579 PMCID: PMC8651638 DOI: 10.1038/s41467-021-27326-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is a rare but fatal disease diagnosed by right heart catheterisation and the exclusion of other forms of pulmonary arterial hypertension, producing a heterogeneous population with varied treatment response. Here we show unsupervised machine learning identification of three major patient subgroups that account for 92% of the cohort, each with unique whole blood transcriptomic and clinical feature signatures. These subgroups are associated with poor, moderate, and good prognosis. The poor prognosis subgroup is associated with upregulation of the ALAS2 and downregulation of several immunoglobulin genes, while the good prognosis subgroup is defined by upregulation of the bone morphogenetic protein signalling regulator NOG, and the C/C variant of HLA-DPA1/DPB1 (independently associated with survival). These findings independently validated provide evidence for the existence of 3 major subgroups (endophenotypes) within the IPAH classification, could improve risk stratification and provide molecular insights into the pathogenesis of IPAH.
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83
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Rosenkranz S, Channick R, Chin KM, Jenner B, Gaine S, Galiè N, Ghofrani HA, Hoeper MM, McLaughlin VV, Du Roure C, Rubin LJ, Sitbon O, Tapson V, Lang IM. The impact of comorbidities on selexipag treatment effect in patients with pulmonary arterial hypertension: insights from the GRIPHON study. Eur J Heart Fail 2021; 24:205-214. [PMID: 34806261 PMCID: PMC9298818 DOI: 10.1002/ejhf.2369] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 09/23/2021] [Accepted: 10/17/2021] [Indexed: 11/23/2022] Open
Abstract
Aims The number of pulmonary arterial hypertension (PAH) patients with comorbidities is increasing and there are limited data on response to PAH‐targeted therapies in this population. These post hoc analyses explored the effect of selexipag in PAH patients with cardiovascular comorbidities in the GRIPHON study. Methods and results Randomized patients (n = 1156) were classified using three methods: (i) by subgroups defined according to previously published comorbidity count and restrictive haemodynamic criteria: Subgroup A (<3 comorbidities and haemodynamic criteria met; n = 962) and Subgroup B (≥3 comorbidities and/or haemodynamic criteria not met; n = 144); comorbidities included body mass index ≥30 kg/m2, essential hypertension, diabetes, history of coronary artery disease; (ii) by number of comorbidities, with addition of atrial fibrillation (0, 1, 2, 3, 4, or 5); (iii) by presence of individual comorbidities. Selexipag to placebo hazard ratios (HR) and 95% confidence intervals (CI) for morbidity/mortality (primary composite endpoint) were estimated using Cox regression adjusting selexipag effect for baseline covariates. Approximately half of the patients in GRIPHON (n = 584; 50.5%) had comorbidities. Selexipag reduced the risk of a morbidity/mortality event compared with placebo in both Subgroup A (HR 0.66, 95% CI 0.53, 0.82) and Subgroup B (HR 0.50, 95% CI 0.26, 0.96), with no evidence of an inconsistent treatment effect between subgroups (interaction p = 0.432). Consistent results were observed in analyses by number and by specific type of comorbidity. Conclusion Selexipag reduces the risk of a morbidity/mortality event vs. placebo irrespective of patient comorbidity status, suggesting that comorbidity status does not influence the treatment effect of selexipag.
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Affiliation(s)
- Stephan Rosenkranz
- Heart Center, University Hospital Cologne, and Cologne Cardiovascular Research Center (CCRC), Cologne, Germany
| | | | | | | | - Sean Gaine
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Nazzareno Galiè
- DIMES, University of Bologna and IRCCS, S. Orsola University Hospital, Bologna, Italy
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Giessen, Germany, member of the German Center for Lung Research, and Department of Medicine, Imperial College London, London, UK
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center for Lung Research, Hannover, Germany
| | | | | | - Lewis J Rubin
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Olivier Sitbon
- Hôpital Universitaire de Bicêtre, Université Paris-Sud, Le Kremlin Bicêtre, France
| | | | - Irene M Lang
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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84
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Predictive value of chest HRCT for survival in idiopathic pulmonary arterial hypertension. Respir Res 2021; 22:293. [PMID: 34789251 PMCID: PMC8597242 DOI: 10.1186/s12931-021-01893-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/09/2021] [Indexed: 11/15/2022] Open
Abstract
Background Little attention has been paid to chest high resolution computed tomography (HRCT) findings in idiopathic pulmonary arterial hypertension (IPAH) patients so far, while a couple of small studies suggested that presence of centrilobular ground-glass opacifications (GGO) on lung scans could have a significant negative prognostic value. Therefore, the aims of the present study were: to assess frequency and clinical significance of GGO in IPAH, and to verify if it carries an add-on prognostic value in reference to multidimensional risk assessment tool recommended by the 2015 European pulmonary hypertension guidelines. Methods Chest HRCT scans of 110 IPAH patients were retrospectively analysed. Patients were divided into three groups: with panlobular (p)GGO, centrilobular (c)GGO, and normal lung pattern. Association of different GGO patterns with demographic, functional, haemodynamic, and biochemical parameters was tested. Survival analysis was also performed. Results GGO were found in 46% of the IPAH patients: pGGO in 24% and cGGO in 22%. Independent predictors of pGGO were: positive history of haemoptysis, higher number of low-risk factors, and lower cardiac output. Independent predictors of cGGO were: positive history of haemoptysis, younger age, higher right atrial pressure, and higher mixed venous blood oxygen saturation. CGGO had a negative prognostic value for outcome in a 2-year perspective. This effect was not seen in the longer term, probably due to short survival of cGGO patients. Conclusions Lung HRCT carries a significant independent prognostic information in IPAH, and in patients with cGGO present on the scans an early referral to lung transplantation centres should be considered.
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85
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Hoeper MM, Pausch C, Olsson KM, Huscher D, Pittrow D, Grünig E, Staehler G, Vizza CD, Gall H, Distler O, Opitz C, Gibbs JSR, Delcroix M, Ghofrani HA, Park DH, Ewert R, Kaemmerer H, Kabitz HJ, Skowasch D, Behr J, Milger K, Halank M, Wilkens H, Seyfarth HJ, Held M, Dumitrescu D, Tsangaris I, Vonk-Noordegraaf A, Ulrich S, Klose H, Claussen M, Lange TJ, Rosenkranz S. COMPERA 2.0: A refined 4-strata risk assessment model for pulmonary arterial hypertension. Eur Respir J 2021; 60:13993003.02311-2021. [PMID: 34737226 PMCID: PMC9260123 DOI: 10.1183/13993003.02311-2021] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/29/2021] [Indexed: 11/27/2022]
Abstract
Background Risk stratification plays an essential role in the management of patients with pulmonary arterial hypertension (PAH). The current European guidelines propose a three-stratum model to categorise risk as low, intermediate or high, based on the expected 1-year mortality. However, with this model, most patients are categorised as intermediate risk. We investigated a modified approach based on four risk categories, with intermediate risk subdivided into intermediate-low and intermediate-high risk. Methods We analysed data from the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA), a European pulmonary hypertension registry, and calculated risk at diagnosis and first follow-up based on World Health Organization functional class, 6-min walk distance (6MWD) and serum levels of brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP), using refined cut-off values. Survival was assessed using Kaplan–Meier analyses, log-rank testing and Cox proportional hazards models. Results Data from 1655 patients with PAH were analysed. Using the three-stratum model, most patients were classified as intermediate risk (76.0% at baseline and 63.9% at first follow-up). The refined four-stratum risk model yielded a more nuanced separation and predicted long-term survival, especially at follow-up assessment. Changes in risk from baseline to follow-up were observed in 31.1% of the patients with the three-stratum model and in 49.2% with the four-stratum model. These changes, including those between the intermediate-low and intermediate-high strata, were associated with changes in long-term mortality risk. Conclusions Modified risk stratification using a four-stratum model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically relevant changes in risk than the original three-stratum model. COMPERA 2.0, a four-stratum risk assessment model based on refined cut-off levels for functional class, 6MWD and BNP/NT-proBNP was more sensitive to prognostically significant changes in risk than the original three-stratum modelhttps://bit.ly/3mzPKjA
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany .,German Center of Lung Research (DZL), Germany
| | | | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,German Center of Lung Research (DZL), Germany
| | - Doerte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - David Pittrow
- GWT-TUD GmbH, Epidemiological Centre, Dresden, Germany.,Institute for Clinical Pharmacology, Medical Faculty, Technical University, Dresden, Germany
| | - Ekkehard Grünig
- Center for Pulmonary Hypertension, Thoraxklinik at Heidelberg University Hospital, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | | | - Carmine Dario Vizza
- Dipartimento di Scienze Cliniche Internistiche, Anestiologiche e Cardiolohiche, Sapienza, University of Rome, Rome, Italy
| | - Henning Gall
- German Center of Lung Research (DZL), Germany.,Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Oliver Distler
- Department of Rheumatology, University Hospital, Zurich, Switzerland
| | - Christian Opitz
- Department of Cardiology, DRK Kliniken Berlin Westend, Berlin, Germany
| | - J Simon R Gibbs
- Department of Cardiology, National Heart & Lung Institute; Imperial College London, London, United Kingdom
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - H Ardeschir Ghofrani
- German Center of Lung Research (DZL), Germany.,Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany.,Department of Medicine, Imperial College London, London, United Kingdom
| | - Da-Hee Park
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Ralf Ewert
- Clinic of Internal Medicine, Department of Respiratory Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Harald Kaemmerer
- Deutsches Herzzentrum München, Klinik für angeborene Herzfehler und Kinderkardiologie; TU München, Munich, Germany
| | - Hans-Joachim Kabitz
- Gemeinnützige Krankenhausbetriebsgesellschaft Konstanz mbH, Medizinische Klinik II, Konstanz, Germany
| | - Dirk Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik und Poliklinik II, Innere Medizin - Kardiologie/Pneumologie, Bonn, Germany
| | - Juergen Behr
- Comprehensive Pneumology Center, Lungenforschungsambulanz, Helmholtz Zentrum, München, Germany.,Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Katrin Milger
- Department of Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Michael Halank
- Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Heinrike Wilkens
- Klinik für Innere Medizin V, Pneumologie, Universitätsklinikum Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans-Jürgen Seyfarth
- Universitätsklinikum Leipzig, Medizinische Klinik und Poliklinik II, Abteilung für Pneumologie, Leipzig, Germany
| | - Matthias Held
- Department of Internal Medicine, Respiratory Medicine and Ventilatory Support, Medical Mission Hospital, Central Clinic Würzburg, Würzburg, Germany
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Iraklis Tsangaris
- Attikon University Hospital, 2nd Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Anton Vonk-Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, , Amsterdam, Netherlands
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Hans Klose
- Department of Respiratory Medicine, Eppendorf University Hospital, Hamburg, Germany
| | - Martin Claussen
- LungenClinic Grosshansdorf, Fachabteilung Pneumologie, Großhansdorf, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine (CMMC), and the Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
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Scott TE, Qin CX, Drummond GR, Hobbs AJ, Kemp-Harper BK. Innovative Anti-Inflammatory and Pro-resolving Strategies for Pulmonary Hypertension: High Blood Pressure Research Council of Australia Award 2019. Hypertension 2021; 78:1168-1184. [PMID: 34565184 DOI: 10.1161/hypertensionaha.120.14525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertension is a rare, ostensibly incurable, and etiologically diverse disease with an unacceptably high 5-year mortality rate (≈50%), worse than many cancers. Irrespective of pathogenic origin, dysregulated immune processes underlie pulmonary hypertension pathobiology, particularly pertaining to pulmonary vascular remodeling. As such, a variety of proinflammatory pathways have been mooted as novel therapeutic targets. One such pathway involves the family of innate immune regulators known as inflammasomes. In addition, a new and emerging concept is differentiating between anti-inflammatory approaches versus those that promote pro-resolving pathways. This review will briefly introduce inflammasomes and examine recent literature concerning their role in pulmonary hypertension. Moreover, it will explore the difference between inflammation-suppressing and pro-resolution approaches and how this links to inflammasomes. Finally, we will investigate new avenues for targeting inflammation in pulmonary hypertension via more targeted anti-inflammatory or inflammation resolving strategies.
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Affiliation(s)
- Tara E Scott
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute (T.E.S., B.K.K.-H.), Monash University, Parkville, VIC, Australia
- Monash University, Clayton, VIC, Australia and Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences (T.E.S., C.X.Q.), Monash University, Parkville, VIC, Australia
| | - Cheng Xue Qin
- Monash University, Clayton, VIC, Australia and Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences (T.E.S., C.X.Q.), Monash University, Parkville, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia (C.X.Q.)
| | - Grant R Drummond
- Centre for Cardiovascular Biology and Disease Research, Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, Australia (G.R.D.)
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (A.J.H.)
| | - Barbara K Kemp-Harper
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute (T.E.S., B.K.K.-H.), Monash University, Parkville, VIC, Australia
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87
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Zelt JGE, Sugarman J, Weatherald J, Partridge ACR, Liang JC, Swiston J, Brunner N, Chandy G, Stewart DJ, Contreras-Dominguez V, Thakrar M, Helmersen D, Varughese R, Hirani N, Umar F, Dunne R, Doyle-Cox C, Foxall J, Mielniczuk L. Mortality trends in pulmonary arterial hypertension in canada: a temporal analysis of survival per ESC/ERS Guideline Era. Eur Respir J 2021; 59:13993003.01552-2021. [PMID: 34675044 PMCID: PMC9160389 DOI: 10.1183/13993003.01552-2021] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/06/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The evolution in pulmonary arterial hypertension (PAH) management has been summarized in three iterations of the European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines. No study has assessed whether changes in management, as reflected in the changing guidelines, has translated to improved long-term survival in PAH. METHODS Mixed retrospective/prospective analysis of treatment naïve, incident PAH patients (n=392) diagnosed at three major centers in Canada from 2009-2021. Patients were divided into two groups based on their diagnosis date and in accordance with three ESC/ERS guideline iterations: 2009 and 2015. Overall survival was assessed based on date of diagnosis and initial treatment strategy (i.e. mono versus combination). RESULTS In Canada, there was a shift towards more aggressive upfront management with combination therapy after the publication of the 2015 guidelines (10.4% and 30.8% in 2009-2015 patients, and 36.0% and 57.4% in 2016-2021 patients, for baseline and 2-year follow-up respectively). A key factor associated with combination therapy after 2015 was higher pulmonary vascular resistance (p=0.009). The 1, 3 and 5 year survival rates in Canada were 89.2%, 75.6%. and 56.0%, respectively. Despite changes in management, there was no improvement in long-term survival before and after publication of the 2015 ESC/ERS guideline (p=0.53). CONCLUSIONS There was an increase in the use of initial and sequential combination therapy in Canada after publication of the 2015 ESC/ERS guidelines, which was not associated with improved long-term survival. These data highlight the continued difficulties of managing this aggressive pulmonary disease in an era without a cure.
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Affiliation(s)
- Jason G E Zelt
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada .,Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Jordan Sugarman
- Internal Medicine Residency Program, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jason Weatherald
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Arun C R Partridge
- Internal Medicine Residency Program, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jiaming Calvin Liang
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - John Swiston
- Division of Respirology, University of British Columbia, Vancouver, Canada
| | - Nathan Brunner
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - George Chandy
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa.,Division of Respirology and Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Duncan J Stewart
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa.,Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Mitesh Thakrar
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Helmersen
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Naushad Hirani
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fraz Umar
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Rosemary Dunne
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Caroyln Doyle-Cox
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Julia Foxall
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
| | - Lisa Mielniczuk
- Department of Cellular and Molecular Medicine and Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa
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Subramanyan R. Avalanches in cardiology. Ann Pediatr Cardiol 2021; 14:401-407. [PMID: 34667416 PMCID: PMC8457267 DOI: 10.4103/apc.apc_235_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 04/05/2021] [Accepted: 05/21/2021] [Indexed: 11/29/2022] Open
Abstract
Sudden cardiac death (SCD) accounts for 15%–60% of mortality in patients with heart disease. Generally, this has been attributed to ventricular tachyarrhythmia. However, ventricular tachyarrhythmia has been documented or strongly suspected on clinical grounds in a relatively small proportion of SCD patients (8%–50%). Attempted prophylaxis of SCD by implantation of cardioverter-defibrillator is associated with variable success in different subsets of high-risk cardiac patients (30%–70%). A significant number of SCD, therefore, appear to be due to catastrophic circulatory failure. Multiple interdependent compensatory mechanisms help to maintain circulation in advanced cardiac disease. Rapid, unexpected, and massive breakdown of the compensated state can be precipitated by small and often imperceptible triggers. The initial critical but stable state followed by rapid circulatory failure and death has been considered to be analogous to snow avalanches. It is typically described in patients with left ventricular (LV) dysfunction (ischemic or nonischemic). It is now recognized that SCD can also happen in conditions where the right ventricle (RV) takes the brunt of the hemodynamic load. Advanced pulmonary arterial hypertension and operated patients of tetralogy of Fallot with pulmonary regurgitation are of particular interest to pediatric cardiologists. A large amount of data is available on LV changes and mechanics, while relatively little information is available on the mechanisms of RV adaptation to increased load and RV failure. Whether the triggers and the decompensatory processes are similar for the two ventricles is a moot point. This article highlights the currently available knowledge on the pathophysiology of SCD in RV overload states, with special reference to RV adaptive and decompensatory mechanisms, and therapeutic measures that can potentially interrupt the vicious downward course (cardiac avalanches).
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Affiliation(s)
- Raghavan Subramanyan
- Department of Pediatric Cardiology, Frontier Lifeline Hospital, Chennai, Tamil Nadu, India
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89
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Jansen SMA, van de Heuvel LM, Houweling AC, van Tintelen JP, de Man FS, Vonk Noordegraaf A, Jan Bogaard H. Uptake and Patient Perspectives on Additional Testing for Novel Disease-Associated Genes: Lessons from a PAH Cohort. Genes (Basel) 2021; 12:genes12101540. [PMID: 34680935 PMCID: PMC8536181 DOI: 10.3390/genes12101540] [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: 08/31/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) has an identifiable genetic cause in 5% of all PAH cases. Due to health benefits conferred by the early detection of PAH and the recent identification of additional PAH-associated genes, we decided to offer (extended) genetic testing to all incident and prevalent idiopathic PAH (iPAH) and pulmonary veno-occlusive disease (PVOD) patients in our clinic. Here, we report the lessons learned from (re-)contacting iPAH/PVOD patients concerning the uptake and analysis of identified PAH-associated genes and patient perspectives of the approach. Methods: Between January 2018 and April 2020, all iPAH/PVOD patients who were not previously genetically tested (contact group) and those who tested negative on prior analysis of BMPR2 and SMAD9 variants (re-contact group) were (re-)contacted for (additional) genetic testing. Results: With our approach, 58% of patients (84 out of 165) opted for genetic counselling, and a pathogenic variant was found in 12% of cases (n = 10) (re-contact group, 11%, and contact group, 13%). Eighty-six percent of participants of the survey study appreciated being (re-)contacted for genetic testing. Mild psychosocial impacts were observed. Conclusions: Our report shows the importance of (re-)contact and interest of patients (as indicated by the uptake, mild psychosocial impact and appreciation) in PAH.
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Affiliation(s)
- Samara M. A. Jansen
- Department of Pulmonary Medicine, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (S.M.A.J.); (F.S.d.M.); (A.V.N.)
| | - Lieke M. van de Heuvel
- Department of Human Genetics, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (L.M.v.d.H.); (A.C.H.); (J.P.v.T.)
- University Medical Centre Utrecht, Department of Genetics, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Arjan C. Houweling
- Department of Human Genetics, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (L.M.v.d.H.); (A.C.H.); (J.P.v.T.)
| | - J. Peter van Tintelen
- Department of Human Genetics, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (L.M.v.d.H.); (A.C.H.); (J.P.v.T.)
- University Medical Centre Utrecht, Department of Genetics, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Frances S. de Man
- Department of Pulmonary Medicine, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (S.M.A.J.); (F.S.d.M.); (A.V.N.)
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (S.M.A.J.); (F.S.d.M.); (A.V.N.)
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Center (UMC) (Vrije Universiteit), 1081 HV Amsterdam, The Netherlands; (S.M.A.J.); (F.S.d.M.); (A.V.N.)
- Correspondence:
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Sun Y, Sangam S, Guo Q, Wang J, Tang H, Black SM, Desai AA. Sex Differences, Estrogen Metabolism and Signaling in the Development of Pulmonary Arterial Hypertension. Front Cardiovasc Med 2021; 8:719058. [PMID: 34568460 PMCID: PMC8460911 DOI: 10.3389/fcvm.2021.719058] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/11/2021] [Indexed: 01/08/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a complex and devastating disease with a poor long-term prognosis. While women are at increased risk for developing PAH, they exhibit superior right heart function and higher survival rates than men. Susceptibility to disease risk in PAH has been attributed, in part, to estrogen signaling. In contrast to potential pathological influences of estrogen in patients, studies of animal models reveal estrogen demonstrates protective effects in PAH. Consistent with this latter observation, an ovariectomy in female rats appears to aggravate the condition. This discrepancy between observations from patients and animal models is often called the "estrogen paradox." Further, the tissue-specific interactions between estrogen, its metabolites and receptors in PAH and right heart function remain complex; nonetheless, these relationships are essential to characterize to better understand PAH pathophysiology and to potentially develop novel therapeutic and curative targets. In this review, we explore estrogen-mediated mechanisms that may further explain this paradox by summarizing published literature related to: (1) the synthesis and catabolism of estrogen; (2) activity and functions of the various estrogen receptors; (3) the multiple modalities of estrogen signaling in cells; and (4) the role of estrogen and its diverse metabolites on the susceptibility to, and progression of, PAH as well as their impact on right heart function.
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Affiliation(s)
- Yanan Sun
- College of Veterinary Medicine, Northwest A&F University, Xianyang, China
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shreya Sangam
- Department of Medicine, Krannert Institute of Cardiology, Indiana University, Indianapolis, IN, United States
| | - Qiang Guo
- Department of Critical Care Medicine, Suzhou Dushu Lake Hospital, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Wang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haiyang Tang
- College of Veterinary Medicine, Northwest A&F University, Xianyang, China
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangdong Key Laboratory of Vascular Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Stephen M. Black
- Department of Cellular Biology and Pharmacology, Herbert Wertheim College of Medicine, Miami, FL, United States
- Center for Translational Science and Department of Environmental Health Sciences, Robert Stempel College of Public Health and Social Work, Florida International University, Port St. Lucie, FL, United States
| | - Ankit A. Desai
- Department of Medicine, Krannert Institute of Cardiology, Indiana University, Indianapolis, IN, United States
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Thoracic Visceral Adipose Tissue Area and Pulmonary Hypertension in Lung Transplant Candidates. The Lung Transplant Body Composition Study. Ann Am Thorac Soc 2021; 17:1393-1400. [PMID: 32530703 DOI: 10.1513/annalsats.202003-247oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Obesity is associated with an increased risk of pulmonary hypertension (PH); however, regional adipose tissue deposition is heterogeneous with distinct cardiovascular phenotypes.Objectives: To determine the association of body mass index (BMI) and thoracic visceral and subcutaneous adipose tissue areas (VAT and SAT, respectively) with PH in patients with advanced lung disease referred for lung transplantation.Methods: We studied patients undergoing evaluation for lung transplantation at three centers from the Lung Transplant Body Composition Study. PH was defined as mean pulmonary artery pressure >20 mm Hg and pulmonary vascular resistance ≥3 Wood units. VAT and SAT were measured on chest computed tomography and normalized to height squared.Results: One hundred thirty-seven (34%) of 399 patients included in our study had PH. Doubling of thoracic VAT was associated with significantly lower pulmonary vascular resistance (β, -0.24; 95% confidence interval [95% CI], -0.46 to -0.02; P = 0.04), higher pulmonary arterial wedge pressure (β, 0.79; 95% CI, 0.32 to 1.26; P = 0.001), and decreased risk of PH (relative risk, 0.86; 95% CI, 0.74 to 0.99; P = 0.04) after multivariate adjustment. Vaspin levels were higher in patients without PH (median, 101.8 vs. 92.0 pg/ml; P < 0.001) but did not mediate the association between VAT and the risk of PH. SAT and BMI were not independently associated with risk of PH.Conclusions: Lower thoracic VAT was associated with a higher risk of PH in patients with advanced lung disease undergoing evaluation for lung transplantation. The role of adipokines in the pulmonary vascular disease remains to be evaluated.
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Zubair A, Waheed S, Shuja F. Psychological impact of cadaveric dissection on first-year medical students. J R Coll Physicians Edinb 2021; 51:392-401. [PMID: 34131680 DOI: 10.4997/jrcpe.2021.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This cross-sectional study was carried out to ascertain if first-time cadaver dissections can cause acute stress disorder (ASD) in medical students, and if death anxiety and gender play a role in the development of these symptoms. METHODS A total of 135 first-year medical students at the Services Institute of Medical Sciences and King Edward Medical University, Lahore, Pakistan, who had recently conducted their first ever cadaver dissection filled out three scales: the Impact of Event Scale-Revised (IES-R), the Appraisal of Life Scale (Revised) (ALS-R) and Death Anxiety Inventory. The results were then calculated via SPSS v.23. Any students with a history of psychiatric treatment or disorder were not included in the study. RESULTS Scores on the IES-R showed that the sample suffered from symptoms of ASD (mean = 36.15, standard deviation = 15.99). Multilinear regression showed that death anxiety did not predict any variance on the scores for IES-R, whereas higher scores on the ALS-R threat domain scale predicted higher scores on the IES-R. Death anxiety had little to no impact on the scores for IES-R. CONCLUSIONS Results showed that students who perceived the dissection situation as threatening and anxiety inducing were more likely to test positively for ASD symptoms. A major limitation of the study was that it did not measure whether these symptoms reduced with repeated exposure to cadaver dissection or how symptoms changed over time.
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Affiliation(s)
- Ambreen Zubair
- South Medical Ward, King Edward Medical University, Lahore, Pakistan
| | - Satia Waheed
- Medical Unit IV Service, Institute of Medical Sciences, Lahore, Pakistan,
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Maximal Exercise Testing Using the Incremental Shuttle Walking Test Can Be Used to Risk-Stratify Patients with Pulmonary Arterial Hypertension. Ann Am Thorac Soc 2021; 18:34-43. [PMID: 32926635 PMCID: PMC7780966 DOI: 10.1513/annalsats.202005-423oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rationale: Exercise capacity predicts mortality in pulmonary arterial hypertension (PAH), but limited data exist on the routine use of maximal exercise testing. Objectives: This study evaluates a simple-to-perform maximal test (the incremental shuttle walking test) and its use in risk stratification in PAH. Methods: Consecutive patients with pulmonary hypertension were identified from the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral centre) registry (2001–2018). Thresholds for levels of risk were identified at baseline and tested at follow-up, and their incorporation into current risk stratification approaches was assessed. Results: Of 4,524 treatment-naive patients with pulmonary hypertension who underwent maximal exercise testing, 1,847 patients had PAH. A stepwise reduction in 1-year mortality was seen between levels 1 (≤30 m; 32% mortality) and 7 (340–420 m; 1% mortality) with no mortality for levels 8–12 (≥430 m) in idiopathic and connective tissue disease–related PAH. Thresholds derived at baseline of ≤180 m (>10%; high risk), 190–330 m (5–10%; intermediate risk), and ≥340 m (<5%; low risk of 1-yr mortality) were applied at follow-up and also accurately identified levels of risk. Thresholds were incorporated into the REVEAL (Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management) 2.0 risk score calculator and French low-risk approach to risk stratification, and distinct categories of risk remained. Conclusions: We have demonstrated that maximal exercise testing in PAH stratifies mortality risk at baseline and follow-up. This study highlights the potential value of the incremental shuttle walking test as an alternative to the 6-minute walking test, combining some of the advantages of maximal exercise testing and maintaining the simplicity of a simple-to-perform field test.
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94
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Mouratoglou SA, Bayoumy AA, Noordegraaf AV. Prediction Models and Scores in Pulmonary Hypertension: A Review. Curr Pharm Des 2021; 27:1266-1276. [PMID: 33155897 DOI: 10.2174/1381612824999201105163437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a serious disease with increased morbidity and mortality. The need for an individualized patient treatment approach necessitates the use of risk assessment in PAH patients. That may include a range of hemodynamic, clinical, imaging and biochemical parameters derived from clinical studies and registry data. OBJECTIVE In the current systematic review, we summarize the available data on risk prognostic models and scores in PAH and we explore the possible concordance amongst different risk stratification tools in PAH. METHODS PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines aided the performance of this systematic review. Eligible studies were identified through a literature search in the electronic databases PubMed, Science Direct, Google Scholar and Cochrane with the use of various combinations of MeSH and non-MeSH terms, with a focus on PAH. RESULTS Overall, 25 studies were included in the systematic review; out of them, 9 were studies deriving prognostic equations and risk scores and 16 were validating studies of an existing score. The majority of risk stratification scores use hemodynamic data for the assessment of prognosis, while others also include clinical and demographic variables in their equations. The risk discrimination in the overall PAH population was adequate, especially in differentiating the low versus high-risk patients, but their discrimination ability in the intermediate groups remained lower. Current ESC/ERS proposed risk stratification score utilizes a limited number of parameters with prognostic significance, whose prognostic ability has been validated in European patient populations. CONCLUSION Despite improvement in risk estimation of prognostic tools of the disease, PAH morbidity and mortality remain high, necessitating the need for the risk scores to undergo periodic re-evaluation and refinements to incorporate new data into predictors of disease progression and mortality and, thereby, maintain their clinical utility.
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Affiliation(s)
- Sophia Anastasia Mouratoglou
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ahmed A Bayoumy
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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95
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Tang SY, Ma HP, Hung CS, Kuo PH, Lin C, Lo MT, Hsu HH, Chiu YW, Wu CK, Tsai CH, Lin YT, Peng CK, Lin YH. The Value of Heart Rhythm Complexity in Identifying High-Risk Pulmonary Hypertension Patients. ENTROPY 2021; 23:e23060753. [PMID: 34203737 PMCID: PMC8232109 DOI: 10.3390/e23060753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/09/2021] [Accepted: 06/12/2021] [Indexed: 11/17/2022]
Abstract
Pulmonary hypertension (PH) is a fatal disease—even with state-of-the-art medical treatment. Non-invasive clinical tools for risk stratification are still lacking. The aim of this study was to investigate the clinical utility of heart rhythm complexity in risk stratification for PH patients. We prospectively enrolled 54 PH patients, including 20 high-risk patients (group A; defined as WHO functional class IV or class III with severely compromised hemodynamics), and 34 low-risk patients (group B). Both linear and non-linear heart rate variability (HRV) variables, including detrended fluctuation analysis (DFA) and multiscale entropy (MSE), were analyzed. In linear and non-linear HRV analysis, low frequency and high frequency ratio, DFAα1, MSE slope 5, scale 5, and area 6–20 were significantly lower in group A. Among all HRV variables, MSE scale 5 (AUC: 0.758) had the best predictive power to discriminate the two groups. In multivariable analysis, MSE scale 5 (p = 0.010) was the only significantly predictor of severe PH in all HRV variables. In conclusion, the patients with severe PH had worse heart rhythm complexity. MSE parameters, especially scale 5, can help to identify high-risk PH patients.
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Affiliation(s)
- Shu-Yu Tang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan; (S.-Y.T.); (C.-S.H.); (P.-H.K.); (C.-K.W.)
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin 640, Taiwan
| | - Hsi-Pin Ma
- Department of Electrical Engineering, National Tsing Hua University, Hsinchu 300044, Taiwan;
| | - Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan; (S.-Y.T.); (C.-S.H.); (P.-H.K.); (C.-K.W.)
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan; (S.-Y.T.); (C.-S.H.); (P.-H.K.); (C.-K.W.)
| | - Chen Lin
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City 330, Taiwan; (C.L.); (M.-T.L.)
| | - Men-Tzung Lo
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan City 330, Taiwan; (C.L.); (M.-T.L.)
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan;
| | - Yu-Wei Chiu
- Department of Computer Science and Engineering, Yuan Ze University, Taoyuan City 330, Taiwan;
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan
| | - Cho-Kai Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan; (S.-Y.T.); (C.-S.H.); (P.-H.K.); (C.-K.W.)
| | - Cheng-Hsuan Tsai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan; (S.-Y.T.); (C.-S.H.); (P.-H.K.); (C.-K.W.)
- Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City 220, Taiwan
- Correspondence: (C.-H.T.); (Y.-T.L.); (Y.-H.L.)
| | - Yen-Tin Lin
- Department of Internal Medicine, Taoyuan General Hospital, Taoyuan City 330, Taiwan
- Correspondence: (C.-H.T.); (Y.-T.L.); (Y.-H.L.)
| | - Chung-Kang Peng
- Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA 02215, USA;
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan; (S.-Y.T.); (C.-S.H.); (P.-H.K.); (C.-K.W.)
- Correspondence: (C.-H.T.); (Y.-T.L.); (Y.-H.L.)
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Kerr KM, Elliott CG, Chin K, Benza RL, Channick RN, Davis RD, He F, LaCroix A, Madani MM, McLaughlin VV, Park M, Robbins IM, Tapson VF, Terry JR, Test VJ, Jain S, Auger WR. Results From the United States Chronic Thromboembolic Pulmonary Hypertension Registry: Enrollment Characteristics and 1-Year Follow-up. Chest 2021; 160:1822-1831. [PMID: 34090871 PMCID: PMC8628169 DOI: 10.1016/j.chest.2021.05.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 11/09/2022] Open
Abstract
Background The United States Chronic Thromboembolic Pulmonary Hypertension Registry (US-CTEPH-R) was designed to characterize the demographic characteristics, evaluation, clinical course, and outcomes of surgical and nonsurgical therapies for patients with chronic thromboembolic pulmonary hypertension. Research Question What are the differences in baseline characteristics and 1-year outcomes between operated and nonoperated subjects? Study Design and Methods This study describes a multicenter, prospective, longitudinal, observational registry of patients newly diagnosed (< 6 months) with CTEPH. Inclusion criteria required a mean pulmonary artery pressure ≥ 25 mm Hg documented by right heart catheterization and radiologic confirmation of CTEPH. Between 2015 and 2018, a total of 750 patients were enrolled and followed up biannually until 2019. Results Most patients with CTEPH (87.9%) reported a history of acute pulmonary embolism. CTEPH diagnosis delays were frequent (median, 10 months), and most patients reported World Health Organization functional class 3 status at enrollment with a median mean pulmonary artery pressure of 44 mm Hg. The registry cohort was subdivided into Operable patients undergoing pulmonary thromboendarterectomy (PTE) surgery (n = 566), Operable patients who did not undergo surgery (n = 88), and those who were Inoperable (n = 96). Inoperable patients were older than Operated patients; less likely to be obese; have a DVT history, non-type O blood group, or thrombophilia; and more likely to have COPD or a history of cancer. PTE resulted in a median pulmonary vascular resistance decline from 6.9 to 2.6 Wood units (P < .001) with a 3.9% in-hospital mortality. At 1-year follow-up, Operated patients were less likely treated with oxygen, diuretics, or pulmonary hypertension-targeted therapy compared with Inoperable patients. A larger percentage of Operated patients were World Health Organization functional class 1 or 2 at 1 year (82.9%) compared with the Inoperable (48.2%) and Operable/No Surgery (56%) groups (P < .001). Interpretation Differences exist in the clinical characteristics between patients who exhibited operable CTEPH and those who were inoperable, with the most favorable 1-year outcomes in those who underwent PTE surgery. Clinical Trial Registration ClinicalTrials.gov; No.: NCT02429284; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Kim M Kerr
- University of California San Diego, La Jolla, CA.
| | | | - Kelly Chin
- University of Texas Southwestern, Dallas, TX
| | - Raymond L Benza
- The Ohio State University, Columbus, OH; University of California Los Angeles, Los Angeles, CA
| | - Richard N Channick
- The Ohio State University, Columbus, OH; University of California Los Angeles, Los Angeles, CA
| | | | - Feng He
- University of California San Diego, La Jolla, CA
| | | | | | | | - Myung Park
- Virginia Mason Franciscan Health, Tacoma, WA
| | | | | | | | | | - Sonia Jain
- University of California San Diego, La Jolla, CA
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Echocardiographic Ventricular Septal Motion Abnormalities are Associated With Pre-Capillary Pulmonary Hypertension in Patients With Preserved Left Ventricular Function. Heart Lung Circ 2021; 31:119-127. [PMID: 34088629 DOI: 10.1016/j.hlc.2021.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 02/02/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ventricular septal motion abnormalities (VSMA) are common echocardiographic finding in patients with pulmonary hypertension (PHTN). This study sought to evaluate the relationship between echocardiographic findings and the classification of PHTN. METHODS This study retrospectively studied 146 consecutive patients referred for right heart catheterisation for clinically suspected PHTN. VSMA were defined as any echocardiographic description of leftward abnormal septal motion or position. RESULTS VSMA were present in 42 patients (29%). Patients with VSMA were younger and more likely to have prior pulmonary embolism. They also had less obstructive sleep apnoea, hypertension and dyslipidaemia. By echocardiography, patients with VSMA had lower left ventricular mass, left atrial size and lateral wall E/e' ratio. At cardiac catheterisation, PHTN was confirmed in all (100%) patients with VSMA (compared with 75% in patients without VSMA); 98% with VSMA had elevated pulmonary vascular resistance (compared with 55% without VSMA; p<0.005 for all). VSMA were found to have 91% sensitivity and 51% specificity for the diagnosis of pre-capillary PHTN. On multivariate analysis, VSMA were found to be strong independent predictors for the diagnosis of pre-capillary PHTN (HR, 9.15; 95% CI, 3.0-28.2; p<0.001). Left atrial enlargement was also a strong negative predictor for pre-capillary PHTN (HR, 0.14; 95% CI, 0.05-0.36; p<0.001). CONCLUSION Ventricular septal motion abnormalities were strongly associated with pre-capillary PHTN in patients with suspected PHTN. The findings suggest that patients with VSMA should be further evaluated by right heart catheterisation.
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98
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Church C, Gin-Sing W, Grady D, Johnson M, Kiely DG, Lordan J, Turner N, Wort SJ, Condliffe R. Establishing expert consensus for the optimal approach to holistic risk-management in pulmonary arterial hypertension: a Delphi process and narrative review. Expert Rev Respir Med 2021; 15:1493-1503. [PMID: 34018901 DOI: 10.1080/17476348.2021.1931129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Pulmonary arterial hypertension (PAH) is associated with significant morbidity and reduced life expectancy. Various medical therapies, together with non-medical therapies such as exercise training, have been shown to improve outcomes for patients. We performed a Delphi consensus process to establish optimal approaches to optimizing patient care.Methods: A steering group of PAH experts formulated 38 statements grouped into 6 themes: burden of PAH, risk-stratification, the role of clinical phenotyping in the management of PAH, assessing clinical response to treatment, maximizing the medical treatment pathway and the role of other management options. An online survey was sent to PAH health-care professionals throughout the UK to assess consensus with these statements. Consensus was defined as high if ≥70% and very high if ≥90% of the respondents agreed with a statement. A narrative review for each theme was then performedResults: Consensus was very high in 27 (71%) statements, high in 7 (18%) statements and was not achieved in 4 (11%) statements.Conclusions: Based on the consensus scores, the steering group derived 13 recommendations which, if implemented, should result in improved holistic care of patients with PAH.
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Affiliation(s)
- Colin Church
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Wendy Gin-Sing
- Pulmonary Hypertension Service, Hammersmith Hospital, London, United Kingdom
| | - Duncan Grady
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Trust, Cambridge, United Kingdom
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Jim Lordan
- Pulmonary Vascular Unit, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Nadine Turner
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - S John Wort
- Pulmonary Hypertension Service, Royal Brompton Hospital, London, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom
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Kerr KM, Elliott CG, Benza RL, Channick RN, Chin KM, Davis RD, Jain S, LaCroix AZ, Madani MM, McLaughlin VV, Park MH, Tapson VF, Auger WR. The United States Chronic Thromboembolic Pulmonary Hypertension Registry: Protocol for a Prospective, Longitudinal Study. JMIR Res Protoc 2021; 10:e25397. [PMID: 33848258 PMCID: PMC8188310 DOI: 10.2196/25397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/24/2021] [Accepted: 04/13/2021] [Indexed: 01/23/2023] Open
Abstract
Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare sequela of acute pulmonary embolism that is treatable when recognized. Awareness of this disease has increased with recent advancements in therapeutic options, but delays in diagnosis remain common, and diagnostic and treatment guidelines are often not followed. Data gathered from international registries have improved our understanding of CTEPH, but these data may not be applicable to the US population owing to differences in demographics and medical practice patterns. Objective The US CTEPH Registry (US-CTEPH-R) was developed to provide essential information to better understand the demographics, risk factors, evaluation, and treatment of CTEPH in the United States, as well as the short- and long-term outcomes of surgical and nonsurgical therapies in the modern treatment era. Methods Thirty sites throughout the United States enrolled 750 subjects in this prospective, longitudinal, observational registry of patients newly diagnosed with CTEPH. Enrollment criteria included a mean pulmonary artery pressure ≥25 mmHg by right heart catheterization and radiologic confirmation of CTEPH by a multidisciplinary adjudication committee. Following enrollment, subjects were followed biannually until the conclusion of the study. Quality of life surveys were administered at enrollment and biannually, and all other testing was at the discretion of the treating clinician. Details regarding surgical therapy, balloon pulmonary angioplasty, and medical therapy were collected at enrollment and at follow-up, as well as information related to health care utilization and survival. Results Data from this registry will improve understanding of the demographics, risk factors, and treatment patterns of patients with CTEPH, and the longitudinal impact of therapies on quality of life, health care utilization, and survival. Conclusions This manuscript details the methodology and design of the first large, prospective, longitudinal registry of patients with CTEPH in the United States. Trial Registration ClinicalTrials.gov NCT02429284; https://www.clinicaltrials.gov/ct2/show/NCT02429284 International Registered Report Identifier (IRRID) DERR1-10.2196/25397
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Affiliation(s)
- Kim M Kerr
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, La Jolla, CA, United States
| | - C Greg Elliott
- Department of Medicine, Intermountain Medical Center, Murray, UT, United States
| | - Raymond L Benza
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, United States
| | - Richard N Channick
- Division of Pulmonary and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Kelly M Chin
- Division of Pulmonary and Critical Care, University of Texas Southwestern, Dallas, TX, United States
| | - R Duane Davis
- Thoracic and Cardiac Surgery, AdventHealth Transplant Institute, Orlando, FL, United States
| | - Sonia Jain
- Division of Biostatistics and Bioinformatics, University of California San Diego, La Jolla, CA, United States
| | - Andrea Z LaCroix
- Division of Epidemiology, University of California San Diego, La Jolla, CA, United States
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, United States
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Myung H Park
- Department of Cardiology, Virginia Mason Franciscan Health, Tacoma, WA, United States
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - William R Auger
- Division of Cardiology, Temple University, Philadelphia, PA, United States
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100
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Valentin S, Maurac A, Sitbon O, Beurnier A, Gomez E, Guillaumot A, Textoris L, Fay R, Savale L, Jaïs X, Montani D, Picard F, Mornex JF, Prevot G, Chabot F, Humbert M, Chaouat A. Outcomes of patients with decreased arterial oxyhaemoglobin saturation on pulmonary arterial hypertension drugs. Eur Respir J 2021; 58:13993003.04066-2020. [PMID: 33875491 DOI: 10.1183/13993003.04066-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/22/2021] [Indexed: 11/05/2022]
Abstract
RATIONALE Drugs approved for the treatment of pulmonary arterial hypertension (PAH) improve long-term outcomes. These drugs have pulmonary vasodilator properties which may potentially cause a decrease in arterial oxyhaemoglobin saturation (SaO2) in some patients. OBJECTIVES The present retrospective study of the French PAH Registry aimed to describe clinical characteristics and outcomes of patients showing a ≥3% decrease in SaO2 while treated with PAH drugs. METHODS We reviewed 719 PAH patients. The exclusion criteria were PAH associated with congenital heart disease and PAH with overt features of venous/capillaries involvement. MAIN RESULTS One hundred and seventy-three (24%) patients had a ≥3% decrease in SaO2. At diagnosis, they were older, with a lower diffusion capacity for carbon monoxide and a shorter 6-minute walk distance, when compared to those who did not display a ≥3% decrease in SaO2. The percentage of patients meeting the ESC/ERS low risk criteria at re-evaluation was significantly lower in those with a ≥3% decrease in SaO2 and more patients started long-term oxygen therapy in this group (16% versus 5%, p<0.001). A≥3% decrease in SaO2 was associated with a poorer survival (Hazard Ratio 1.81:95% confidence interval 1.43-2.34; p<0.0001). In a multivariate Cox analysis, a ≥3% decrease in SaO2 was a prognostic factor independent of age at diagnosis and ESC/ERS risk stratification at follow-up. CONCLUSIONS When treated with PAH drugs, a large subset of patients experience a≥3% decrease in SaO2, which is associated with worst long-term outcomes and reduced survival.
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Affiliation(s)
- Simon Valentin
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France.,Faculté de Médecine de Nancy, Inserm UMR_S1116, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Arnaud Maurac
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Olivier Sitbon
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie et de Physiologie Respiratoire, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,Hôpital Marie-Lannelongue, INSERM UMR S 999, Le Plessis-Robinson, France
| | - Antoine Beurnier
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie et de Physiologie Respiratoire, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,Hôpital Marie-Lannelongue, INSERM UMR S 999, Le Plessis-Robinson, France
| | - Emmanuel Gomez
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Anne Guillaumot
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Laura Textoris
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Renaud Fay
- Faculté de Médecine de Nancy, Inserm UMR_S1116, Université de Lorraine, Vandœuvre-lès-Nancy, France.,Clinical Investigation Center 1433, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Laurent Savale
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie et de Physiologie Respiratoire, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,Hôpital Marie-Lannelongue, INSERM UMR S 999, Le Plessis-Robinson, France
| | - Xavier Jaïs
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie et de Physiologie Respiratoire, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,Hôpital Marie-Lannelongue, INSERM UMR S 999, Le Plessis-Robinson, France
| | - David Montani
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie et de Physiologie Respiratoire, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,Hôpital Marie-Lannelongue, INSERM UMR S 999, Le Plessis-Robinson, France
| | - François Picard
- Hôpital du Haut Lévêque, Service de Cardiologie, CHU de Bordeaux, Université de Bordeaux, Pessac, France
| | - Jean-François Mornex
- Service de Pneumologie, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France.,Université Lyon 1, UMR754, INRA, Université de Lyon, Lyon, France
| | - Grégoire Prevot
- Hôpital Larrey, Service de Pneumologie, CHU de Toulouse, Toulouse, France
| | - François Chabot
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France.,Faculté de Médecine de Nancy, Inserm UMR_S1116, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Service de Pneumologie et de Physiologie Respiratoire, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,Hôpital Marie-Lannelongue, INSERM UMR S 999, Le Plessis-Robinson, France
| | - Ari Chaouat
- Pôle des spécialités médicales/département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France .,Faculté de Médecine de Nancy, Inserm UMR_S1116, Université de Lorraine, Vandœuvre-lès-Nancy, France
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