101
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Lang IM, Binder T. Right atrial strain is a surrogate of coupling in the right heart. Eur Heart J Cardiovasc Imaging 2020; 21:863-864. [PMID: 32412596 DOI: 10.1093/ehjci/jeaa104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Thomas Binder
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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102
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Raitière O, Berthelot E, Fauvel C, Guignant P, Si Belkacem N, Sitbon O, Bauer F. The dangerous and contradictory prognostic significance of PVR<3WU when TAPSE<16mm in postcapillary pulmonary hypertension. ESC Heart Fail 2020; 7:2398-2405. [PMID: 32705818 PMCID: PMC7524100 DOI: 10.1002/ehf2.12785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/26/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Aims In 2019, pulmonary vascular resistance (PVR) < 3WU was adopted to stratify patients at low risk in pulmonary hypertension due to left heart disease (PH‐LHD) as well those with isolated PH‐LHD. We sought to evaluate whether supervised machine learning with decision tree analysis, which provides more information than Cox Proportional analysis by forming a hierarchy of multiple covariates, confirms this risk stratification. Methods and results Two hundred two consecutive patients (mean age: 69 ± 11 years, female: 42%) with mean pulmonary artery pressure ≥ 20 mmHg and wedge pressure > 15 mmHg were recruited. Transpulmonary pressure gradient ⩾̸ 12 mmHg, PVR ⩾̸ 3WU, diastolic pressure gradient ⩾̸ 7 mmHg, pulmonary arterial capacitance < 1.1 mL/mmHg, tricuspid annular plane systolic excursion (TAPSE) < 16 mm, peak systolic tissue Doppler velocity < 10 cm/s, right ventricular end‐diastolic area ⩾̸ 25 cm2 were the seven categorical values entered into the model due to their prognostic significance in PH. We used the chi‐squared automatic interaction detection method to predict mortality. Each node and branch were compared using survival analysis at 6‐year follow‐up. Mean pulmonary artery pressure, wedge pressure, cardiac index, and PVR were 40.3 ± 10.0 mmHg, 22.3 ± 7.1 mmHg, 2.9 ± 0.8 L/min/m2, and 3.6 ± 2.1WU, respectively. Among the seven dichotomous, TAPSE was first selected following by PVR. Compared with patients with PVR < 3WU and TAPSE ⩾̸ 16 mm, patients with PVR ⩾̸ 3WU and TAPSE ⩾̸ 16 mm, or patients with PVR ⩾̸ 3WU and TAPSE<16 mm had significantly increased mortality, HR = 3.0, 95% CI = [1.4–6.4], P = 0.006 and HR = 3.3, 95% CI = [1.6–6.9], P = 0.002, respectively, while patients with PVR < 3WU and TAPSE < 16 mm exhibited the worst prognosis, HR = 7.2, 95% CI = [3.3–15.9], P = 0.0001. Conclusions Used for solving regression and classification problems, decision tree analysis confirms that PVR and TAPSE have to be analysed together in PH‐LHD and revealed the dangerous and contradictory prognostic significance of PVR < 3WU when TAPSE<16 mm.
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Affiliation(s)
- Olivier Raitière
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France.,Department of Cardiac Surgery, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Rouen, F76000, France
| | - Emmanuelle Berthelot
- Department of Cardiology, APHP, Le Kremlin-Bicêtre University Hospital, Paris, 94276, France
| | - Charles Fauvel
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Pierre Guignant
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Nassima Si Belkacem
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France
| | - Olivier Sitbon
- Department of Cardiology, APHP, Le Kremlin-Bicêtre University Hospital, Paris, 94276, France.,INSERM UMR_S999, Université Paris-Sud, Hôpital Bicêtre, Le Kremlin-Bicêtre, 94270, France
| | - Fabrice Bauer
- Department of Cardiac Surgery, Advanced Heart Failure Clinic and Pulmonary Hypertension Referral Center 27/76, Rouen University Hospital, Rouen, F76000, France.,Department of Cardiac Surgery, Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Rouen, F76000, France
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103
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Al-Omary MS, Sugito S, Boyle AJ, Sverdlov AL, Collins NJ. Pulmonary Hypertension Due to Left Heart Disease. Hypertension 2020; 75:1397-1408. [DOI: 10.1161/hypertensionaha.119.14330] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is the most common type of PH and is defined as mean pulmonary artery systolic pressure of >20 mm Hg and pulmonary capillary wedge pressure >15 mm Hg during right heart catheterization. LHD may lead to elevated left atrial pressure alone, which in the absence of intrinsic pulmonary vascular disease will result in PH without changes in pulmonary vascular resistance. Persistent elevation in left atrial pressure may, however, also be associated with subsequent pulmonary vascular remodeling, vasoconstriction, and an increase in pulmonary vascular resistance. Hence, there are 2 subgroups of PH due to LHD, isolated postcapillary PH and combined post- and precapillary PH, with these groups have differing clinical implications. Differentiation of pulmonary arterial hypertension and PH due to LHD is critical to guide management planning; however, this may be challenging. Older patients, patients with metabolic syndrome, and patients with imaging and clinical features consistent with left ventricular dysfunction are suggestive of LHD etiology rather than pulmonary arterial hypertension. Hemodynamic measures such as diastolic pressure gradient, transpulmonary gradient, and pulmonary vascular resistance may assist to differentiate pre- from postcapillary PH and offer prognostic insights. However, these are influenced by fluid status and heart failure treatment. Pulmonary arterial hypertension therapies have been trialed in the treatment with concerning results reflecting disease heterogeneity, variation in inclusion criteria, and mixed end point criteria. The aim of this review is to provide an updated definition, discuss possible pathophysiology, clinical aspects, and the available treatment options for PH due to LHD.
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Affiliation(s)
- Mohammed S. Al-Omary
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Stuart Sugito
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
| | - Andrew J. Boyle
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Aaron L. Sverdlov
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Nicholas J. Collins
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
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104
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Wang L, Halliday G, Huot JR, Satoh T, Baust JJ, Fisher A, Cook T, Hu J, Avolio T, Goncharov DA, Bai Y, Vanderpool RR, Considine RV, Bonetto A, Tan J, Bachman TN, Sebastiani A, Mora AL, Machado RF, Goncharova EA, Gladwin MT, Lai YC. Treatment With Treprostinil and Metformin Normalizes Hyperglycemia and Improves Cardiac Function in Pulmonary Hypertension Associated With Heart Failure With Preserved Ejection Fraction. Arterioscler Thromb Vasc Biol 2020; 40:1543-1558. [PMID: 32268788 PMCID: PMC7255946 DOI: 10.1161/atvbaha.119.313883] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) due to left heart disease (group 2), especially in the setting of heart failure with preserved ejection fraction (HFpEF), is the most common cause of PH worldwide; however, at present, there is no proven effective therapy available for its treatment. PH-HFpEF is associated with insulin resistance and features of metabolic syndrome. The stable prostacyclin analog, treprostinil, is an effective and widely used Food and Drug Administration-approved drug for the treatment of pulmonary arterial hypertension. While the effect of treprostinil on metabolic syndrome is unknown, a recent study suggests that the prostacyclin analog beraprost can improve glucose intolerance and insulin sensitivity. We sought to evaluate the effectiveness of treprostinil in the treatment of metabolic syndrome-associated PH-HFpEF. Approach and Results: Treprostinil treatment was given to mice with mild metabolic syndrome-associated PH-HFpEF induced by high-fat diet and to SU5416/obese ZSF1 rats, a model created by the treatment of rats with a more profound metabolic syndrome due to double leptin receptor defect (obese ZSF1) with a vascular endothelial growth factor receptor blocker SU5416. In high-fat diet-exposed mice, chronic treatment with treprostinil reduced hyperglycemia and pulmonary hypertension. In SU5416/Obese ZSF1 rats, treprostinil improved hyperglycemia with similar efficacy to that of metformin (a first-line drug for type 2 diabetes mellitus); the glucose-lowering effect of treprostinil was further potentiated by the combined treatment with metformin. Early treatment with treprostinil in SU5416/Obese ZSF1 rats lowered pulmonary pressures, and a late treatment with treprostinil together with metformin improved pulmonary artery acceleration time to ejection time ratio and tricuspid annular plane systolic excursion with AMPK (AMP-activated protein kinase) activation in skeletal muscle and the right ventricle. CONCLUSIONS Our data suggest a potential use of treprostinil as an early treatment for mild metabolic syndrome-associated PH-HFpEF and that combined treatment with treprostinil and metformin may improve hyperglycemia and cardiac function in a more severe disease.
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Affiliation(s)
- Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- The Third Xiangya Hospital, Central South University; Changsha, Hunan, China
| | - Gunner Halliday
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Joshua R. Huot
- Department of Surgery, Indiana University School of Medicine
| | - Taijyu Satoh
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jeff J. Baust
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Amanda Fisher
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Todd Cook
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Jian Hu
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Theodore Avolio
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Dmitry A. Goncharov
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Yang Bai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Department of Clinical Pharmacology, College of Pharmacy, China Medical University, Shenyang, Liaoning, China
| | | | | | - Andrea Bonetto
- Department of Surgery, Indiana University School of Medicine
| | - Jiangning Tan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Timothy N. Bachman
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Andrea Sebastiani
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
| | - Ana L. Mora
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Roberto F. Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
| | - Elena A. Goncharova
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Mark T. Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh
| | - Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine
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105
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Bashline MJ, Bachman TN, Helbling NL, Nouraie M, Gladwin MT, Simon MA. The Effects of Inhaled Sodium Nitrite on Pulmonary Vascular Impedance in Patients With Pulmonary Hypertension Associated with Heart Failure With Preserved Ejection Fraction. J Card Fail 2020; 26:654-661. [PMID: 32446946 DOI: 10.1016/j.cardfail.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/03/2020] [Accepted: 04/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The severity of pulmonary hypertension (PH) is monitored by measuring pulmonary vascular resistance, which is a steady-state measurement and ignores the pulsatile load encountered by the right ventricle (RV). Pulmonary vascular impedance (PVZ) can depict both steady-state and pulsatile forces, and thus may better predict clinical outcomes. We sought to calculate PVZ in patients with PH associated with heart failure with preserved ejection fraction who were administered inhaled sodium nitrite to better understand the acute effects on afterload. METHODS AND RESULTS Fourteen patients with PH associated with heart failure with preserved ejection fraction underwent right heart catherization and were administered inhaled sodium nitrite. A Fourier transform was used to calculate PVZ for both before and after nitrite for comparison. Inhaled sodium nitrite decreased characteristic impedance (inversely related to proximal pulmonary artery compliance) and total work performed by the RV. RV efficiency improved, defined by a reduction in the total work divided by cardiac output. There was a mild decrease in pulmonary steady-state resistance after the administration of inhaled sodium nitrite, but this effect was not significant. CONCLUSIONS PVZ analysis showed administration of inhaled sodium nitrite was associated with an improvement in pulmonary vascular compliance via a decrease in characteristic impedance, more so than pulmonary steady-state resistance. This effect was associated with improved RV efficiency and total work.
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Affiliation(s)
| | | | | | - Mehdi Nouraie
- Vascular Medicine Institute; Division of Pulmonary, Allergy and Critical Care Medicine
| | - Mark T Gladwin
- Vascular Medicine Institute; Division of Pulmonary, Allergy and Critical Care Medicine; Division of Cardiology and Heart and Vascular Institute
| | - Marc A Simon
- Department of Bioengineering; Vascular Medicine Institute; Division of Pulmonary, Allergy and Critical Care Medicine; Division of Cardiology and Heart and Vascular Institute.
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106
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Manouras A, Johnson J, Lund LH, Nagy AI. Optimizing diastolic pressure gradient assessment. Clin Res Cardiol 2020; 109:1411-1422. [PMID: 32394159 PMCID: PMC7588394 DOI: 10.1007/s00392-020-01641-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/31/2020] [Indexed: 12/25/2022]
Abstract
Aims The diastolic pressure gradient (DPG) has been proposed as a marker pulmonary vascular disease in the setting of left heart failure (HF). However, its diagnostic utility is compromised by the high prevalence of physiologically incompatible negative values (DPGNEG) and the contradictory evidence on its prognostic value. Pressure pulsatility impacts on DPG measurements, thus conceivably, pulmonary artery wedge pressure (PAWP) measurements insusceptible to the oscillatory effect of the V-wave might yield a more reliable DPG assessment. We set out to investigate how the instantaneous PAWP at the trough of the Y-descent (PAWPY) influences the prevalence of DPGNEG and the prognostic value of the resultant DPGY. Methods Hundred and fifty-three consecutive HF patients referred for right heart catheterisation were enrolled prospectively. DPG, as currently recommended, was calculated. Subsequently, PAWPY was measured and the corresponding DPGY was calculated. Results DPGY yielded higher values (median, IQR: 3.2, 0.6–5.7 mmHg) than DPG (median, IQR: 0.9, − 1.7–3.8 mmHg); p < 0.001. Conventional DPG was negative in 45% of the patients whereas DPGY in only 15%. During follow-up (22 ± 14 months) 58 patients have undergone heart-transplantation or died. The predictive ability of DPGY ≥ 6 mmHg for the above defined end-point events was significant [HR 2.1; p = 0.007] and independent of resting mean pulmonary artery pressure (PAPM). In contrast, conventional DPG did not comprise significant prognostic value following adjustment for PAPM. Conclusion Instantaneous pressures at the trough of Y-descent yield significantly fewer DPGNEG than conventional DPG and entail superior prognostic value in HF patients with and without PH. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01641-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aristomenis Manouras
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Johnson
- Centre for Fetal Medicine Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden.,Theme of Heart and Vessels, Karolinska University Hospital, Stockholm, Sweden
| | - Anikó Ilona Nagy
- Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden. .,Heart and Vascular Center, Semmelweis University, 68. Városmajor u., Budapest, 1026, Hungary.
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107
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Kim MN, Park SM. Heart failure with preserved ejection fraction: insights from recent clinical researches. Korean J Intern Med 2020; 35:514-534. [PMID: 32392659 PMCID: PMC7214356 DOI: 10.3904/kjim.2020.104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for nearly half of the cases of HF and its incidence might be increasing with the aging society. Patients with HFpEF present with significant symptoms, including exercise intolerance, impaired quality of life, and have a poor prognosis as well as frequent hospitalization and increased mortality compared with HF with reduced ejection fraction. The concept of HFpEF is still evolving and may be a virtual complex rather than a real systemic disorder. Thus, beyond solely targeting cardiac abnormalities management strategies need to be extended, such as left ventricular diastolic dysfunction. In this review, we examine new diagnostic algorithms, pathophysiology, current management status, and ongoing trials based on heterogeneous pathophysiology and etiology in HFpEF.
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Affiliation(s)
- Mi-Na Kim
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea
| | - Seong-Mi Park
- Division of Cardiology, Korea University Anam Hospital, Seoul, Korea
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108
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109
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Sara JDS, Maor E, Borlaug B, Lewis BR, Orbelo D, Lerman LO, Lerman A. Non-invasive vocal biomarker is associated with pulmonary hypertension. PLoS One 2020; 15:e0231441. [PMID: 32298301 PMCID: PMC7162478 DOI: 10.1371/journal.pone.0231441] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/08/2020] [Indexed: 12/19/2022] Open
Abstract
Emerging data suggest that noninvasive voice biomarker analysis is associated with coronary artery disease. We recently showed that a vocal biomarker was associated with hospitalization and heart failure in patients with heart failure. We evaluate the association between a vocal biomarker and invasively measured indices of pulmonary hypertension (PH). Patients were referred for an invasive cardiac hemodynamic study between January 2017 and December 2018, and had their voices recorded on three separate occasions to their smartphone prior to each study. A pre-established vocal biomarker was determined based on each individual recording. The intra-class correlation co-efficient between the separate voice recording biomarker values for each individual participant was 0.829 (95% CI 0.740-0.889) implying very good agreement between values. Thus, the mean biomarker was calculated for each patient. Patients were divided into two groups: high pulmonary arterial pressure (PAP) defined as ≥ 35 mmHg (moderate or greater PH), versus lower PAP. Eighty three patients, mean age 61.6 ± 15.1 years, 37 (44.6%) male, were included. Patients with a high mean PAP (≥ 35 mmHg) had on average significantly higher values of the mean voice biomarker compared to those with a lower mean PAP (0.74 ± 0.85 vs. 0.40 ± 0.88 p = 0.046). Multivariate logistic regression showed that an increase in the mean voice biomarker by 1 unit was associated with a high PAP, odds ratio 2.31, 95% CI 1.05-5.07, p = 0.038. This study shows a relationship between a noninvasive vocal biomarker and an invasively derived hemodynamic index related to PH obtained during clinically indicated cardiac catheterization. These results may have important practical clinical implications for telemedicine and remote monitoring of patients with heart failure and PH.
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Affiliation(s)
- Jaskanwal Deep Singh Sara
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN, United States of America
| | - Elad Maor
- Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Barry Borlaug
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN, United States of America
| | - Bradley R. Lewis
- Division of Biomedical Statistics and Informatics, Mayo College of Medicine, Rochester, MN, United States of America
| | - Diana Orbelo
- Divison of Laryngology, Mayo College of Medicine, Rochester, MN, United States of America
| | - Lliach O. Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States of America
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, MN, United States of America
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110
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Lang IM. Diastolic Pulmonary Artery to Pulmonary Capillary Wedge Pressure Difference: A Predictor of Outcome After Left Ventricular Assist Device Implantation. J Am Heart Assoc 2020; 9:e016110. [PMID: 32223392 PMCID: PMC7428647 DOI: 10.1161/jaha.120.016110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Irene M Lang
- Division of Cardiology Department of Internal Medicine II Vienna General Hospital Vienna Austria
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111
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Sugimoto K, Yoshihisa A, Nakazato K, Yokokawa T, Misaka T, Oikawa M, Kobayashi A, Yamaki T, Kunii H, Ishida T, Takeishi Y. Significance of Pulmonary Vascular Resistance and Diastolic Pressure Gradient on the New Definition of Combined Post-Capillary Pulmonary Hypertension. Int Heart J 2020; 61:301-307. [DOI: 10.1536/ihj.19-476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Koichi Sugimoto
- Department of Cardiovascular Medicine, Fukushima Medical University
- Department of Pulmonary Hypertension, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University
- Department of Pulmonary Hypertension, Fukushima Medical University
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Takafumi Ishida
- Department of Cardiovascular Medicine, Fukushima Medical University
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112
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Shah SJ, Borlaug BA, Kitzman DW, McCulloch AD, Blaxall BC, Agarwal R, Chirinos JA, Collins S, Deo RC, Gladwin MT, Granzier H, Hummel SL, Kass DA, Redfield MM, Sam F, Wang TJ, Desvigne-Nickens P, Adhikari B. Research Priorities for Heart Failure With Preserved Ejection Fraction: National Heart, Lung, and Blood Institute Working Group Summary. Circulation 2020; 141:1001-1026. [PMID: 32202936 PMCID: PMC7101072 DOI: 10.1161/circulationaha.119.041886] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF), a major public health problem that is rising in prevalence, is associated with high morbidity and mortality and is considered to be the greatest unmet need in cardiovascular medicine today because of a general lack of effective treatments. To address this challenging syndrome, the National Heart, Lung, and Blood Institute convened a working group made up of experts in HFpEF and novel research methodologies to discuss research gaps and to prioritize research directions over the next decade. Here, we summarize the discussion of the working group, followed by key recommendations for future research priorities. There was uniform recognition that HFpEF is a highly integrated, multiorgan, systemic disorder requiring a multipronged investigative approach in both humans and animal models to improve understanding of mechanisms and treatment of HFpEF. It was recognized that advances in the understanding of basic mechanisms and the roles of inflammation, macrovascular and microvascular dysfunction, fibrosis, and tissue remodeling are needed and ideally would be obtained from (1) improved animal models, including large animal models, which incorporate the effects of aging and associated comorbid conditions; (2) repositories of deeply phenotyped physiological data and human tissue, made accessible to researchers to enhance collaboration and research advances; and (3) novel research methods that take advantage of computational advances and multiscale modeling for the analysis of complex, high-density data across multiple domains. The working group emphasized the need for interactions among basic, translational, clinical, and epidemiological scientists and across organ systems and cell types, leveraging different areas or research focus, and between research centers. A network of collaborative centers to accelerate basic, translational, and clinical research of pathobiological mechanisms and treatment strategies in HFpEF was discussed as an example of a strategy to advance research progress. This resource would facilitate comprehensive, deep phenotyping of a multicenter HFpEF patient cohort with standardized protocols and a robust biorepository. The research priorities outlined in this document are meant to stimulate scientific advances in HFpEF by providing a road map for future collaborative investigations among a diverse group of scientists across multiple domains.
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Affiliation(s)
- Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | | | | | | | | | | | | | | | - Scott L. Hummel
- University of Michigan and the Ann Arbor Veterans Affairs Health System, Ann Arbor, MI
| | | | | | - Flora Sam
- Boston University School of Medicine, Boston, MA
| | | | | | - Bishow Adhikari
- National Heart, Lung, and Blood Institute, National Institute of Health, Bethesda, MD
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113
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Erqou S, Lodebo BT, Masri A, Altibi AM, Echouffo-Tcheugui JB, Dzudie A, Ataklte F, Choudhary G, Bloomfield GS, Wu WC, Kengne AP. Cardiac Dysfunction Among People Living With HIV: A Systematic Review and Meta-Analysis. JACC-HEART FAILURE 2020; 7:98-108. [PMID: 30704613 DOI: 10.1016/j.jchf.2018.10.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 09/26/2018] [Accepted: 10/04/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To synthesize existing epidemiological data on cardiac dysfunction in HIV. BACKGROUND Data on the burden and risk of human immunodeficiency virus (HIV) infection-associated cardiac dysfunction have not been adequately synthesized. We performed meta-analyses of extant literature on the frequency of several subtypes of cardiac dysfunction among people living with HIV. METHODS We searched electronic databases and reference lists of review articles and combined the study-specific estimates using random-effects model meta-analyses. Heterogeneity was explored using subgroup analyses and meta-regressions. RESULTS We included 63 reports from 54 studies comprising up to 125,382 adults with HIV infection and 12,655 cases of various cardiac dysfunctions. The pooled prevalence (95% confidence interval) was 12.3% (6.4% to 19.7%; 26 studies) for left ventricular systolic dysfunction (LVSD); 12.0% (7.6% to 17.2%; 17 studies) for dilated cardiomyopathy; 29.3% (22.6% to 36.5%; 20 studies) for grades I to III diastolic dysfunction; and 11.7% (8.5% to 15.3%; 11 studies) for grades II to III diastolic dysfunction. The pooled incidence and prevalence of clinical heart failure were 0.9 per 100 person-years (0.4 to 2.1 per 100 person-years; 4 studies) and 6.5% (4.4% to 9.6%; 8 studies), respectively. The combined prevalence of pulmonary hypertension and right ventricular dysfunction were 11.5% (5.5% to 19.2%; 14 studies) and 8.0% (5.2% to 11.2%; 10 studies), respectively. Significant heterogeneity was observed across studies for all the outcomes analyzed (I2 > 70%, p < 0.01), only partly explained by available study level characteristics. There was a trend for lower prevalence of LVSD in studies reporting higher antiretroviral therapy use or lower proportion of acquired immune deficiency syndrome. The prevalence of LVSD was higher in the African region. After taking into account the effect of regional variation, there was evidence of lower prevalence of LVSD in studies published more recently. CONCLUSIONS Cardiac dysfunction is frequent in people living with HIV. Additional prospective studies are needed to better understand the burden and risk of various forms of cardiac dysfunction related to HIV and the associated mechanisms. (Cardiac dysfunction in people living with HIV-a systematic review and meta-analysis; CRD42018095374).
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Affiliation(s)
- Sebhat Erqou
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island; Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island.
| | | | - Ahmad Masri
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. https://twitter.com/MasriAhmadMD
| | - Ahmed M Altibi
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Anastase Dzudie
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Feven Ataklte
- Department of Medicine, Boston University, Boston, Massachusetts
| | - Gaurav Choudhary
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island; Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island. https://twitter.com/GChoudharyMD
| | - Gerald S Bloomfield
- Duke Clinical Research Institute, Duke Global Health Institute and Department of Medicine, Duke University, Durham, North Carolina
| | - Wen-Chih Wu
- Department of Medicine, Providence VA Medical Center, Providence, Rhode Island; Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andre Pascal Kengne
- South African Medical Research Council and University of Cape Town, South Africa
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Nishihara T, Yamamoto E, Tokitsu T, Sueta D, Fujisue K, Usuku H, Takashio S, Sakamoto K, Kaikita K, Tsujita K. New Definition of Pulmonary Hypertension in Patients with Heart Failure with Preserved Ejection Fraction. Am J Respir Crit Care Med 2020; 200:386-388. [PMID: 30917008 DOI: 10.1164/rccm.201901-0148le] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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115
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Pi H, Kosanovich CM, Handen A, Tao M, Visina J, Vanspeybroeck G, Simon MA, Risbano MG, Desai A, Mathier MA, Rivera-Lebron BN, Nguyen Q, Kliner J, Nouraie M, Chan SY. Outcomes of Pulmonary Arterial Hypertension Are Improved in a Specialty Care Center. Chest 2020; 158:330-340. [PMID: 32109446 DOI: 10.1016/j.chest.2020.01.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 12/22/2019] [Accepted: 01/26/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressures and is managed by vasodilator therapies. Current guidelines encourage PAH management in specialty care centers (SCCs), but evidence is sparse regarding improvement in clinical outcomes and correlation to vasodilator use with referral. RESEARCH QUESTION Is PAH management at SCCs associated with improved clinical outcomes? STUDY DESIGNAND METHODS A single-center, retrospective study was performed at the University of Pittsburgh Medical Center (UPMC; overseeing 40 hospitals). Patients with PAH were identified between 2008 and 2018 and classified into an SCC or non-SCC cohort. Cox proportional hazard modeling was done to compare for all-cause mortality, as was negative binomial regression modeling for hospitalizations. Vasodilator therapy was included to adjust outcomes. RESULTS Of 580 patients with PAH at UPMC, 455 (78%) were treated at the SCC, comprising a younger (58.8 vs 64.8 years; P < .001) and more often female (68.4% vs 51.2%; P < .001) population with more comorbidities without differences in race or income. SCC patients demonstrated improved survival (hazard ratio, 0.68; P = .012) and fewer hospitalizations (incidence ratio, 0.54; P < .001), and provided more frequent disease monitoring. Early patient referral to SCC (< 6 months from time of diagnosis) was associated with improved outcomes compared with non-SCC patients. SCC patients were more frequently prescribed vasodilators (P < .001) and carried more diagnostic PAH coding (P < .001). Vasodilators were associated with improved outcomes irrespective of location but without statistical significance when comparing between locations (P > .05). INTERPRETATION The UPMC SCC demonstrated improved outcomes in mortality and hospitalizations. The SCC benefit was multifactorial, with more frequent vasodilator therapy and disease monitoring. These findings provide robust evidence for early and regular referral of patients with PAH to SCCs.
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Affiliation(s)
- Hongyang Pi
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Chad M Kosanovich
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adam Handen
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA
| | - Michael Tao
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jacqueline Visina
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Marc A Simon
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael G Risbano
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Aken Desai
- Division of Cardiovascular Medicine, University of Colorado, Aurora, CO
| | - Michael A Mathier
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Belinda N Rivera-Lebron
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Quyen Nguyen
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer Kliner
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen Y Chan
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Pittsburgh, PA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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116
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Rivinius R, Helmschrott M, Ruhparwar A, Schmack B, Darche FF, Thomas D, Bruckner T, Doesch AO, Katus HA, Ehlermann P. Elevated pre-transplant pulmonary vascular resistance is associated with early post-transplant atrial fibrillation and mortality. ESC Heart Fail 2020; 7:176-187. [PMID: 32197001 PMCID: PMC7083465 DOI: 10.1002/ehf2.12549] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/16/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Severely elevated pre-transplant pulmonary vascular resistance (PVR) has been linked to adverse effects after heart transplantation (HTX). The impact of a moderately increased PVR before HTX on post-transplant outcomes remains uncertain. The aim of this study was to investigate the effects of an elevated pre-transplant PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units) on outcomes after HTX. METHODS AND RESULTS This observational retrospective single-centre study included 561 patients receiving HTX at Heidelberg Heart Center between 1989 and 2015. Patients were stratified by degree of pre-transplant PVR. Analyses covered demographics, post-transplant medication, mortality and causes of death after HTX, early post-transplant atrial fibrillation (AF), and length of the initial hospital stay after HTX. Ninety-four patients (16.8%) had a PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units). These patients had a higher rate of early post-transplant AF [20.2 vs. 10.7%, difference: 9.5%, 95% confidence interval (CI): 0.9-18.1%, P = 0.01] and an increased 30 day post-transplant mortality (25.5 vs. 6.4%, hazard ratio: 4.4, 95% CI: 2.6-7.6, P < 0.01), along with a higher percentage of death due to transplant failure (21.2 vs. 4.1%, difference: 17.1%, 95% CI: 8.7-25.5%, P < 0.01). Multivariate analysis revealed a PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units) as a significant risk factor for increased 30 day mortality after HTX (hazard ratio: 4.4, 95% CI: 2.5-7.6, P < 0.01). Kaplan-Meier estimator showed a lower 2 year survival after HTX (P < 0.01) in patients with a PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units). CONCLUSIONS Elevated pre-transplant PVR ≥ 300 dyn·s·cm-5 (≥3.75 Wood units) is associated with early post-transplant AF and increased mortality after HTX.
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Affiliation(s)
- Rasmus Rivinius
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
- Heidelberg Center for Heart Rhythm Disorders (HCR)Heidelberg University HospitalHeidelbergGermany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/MannheimHeidelbergGermany
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Arjang Ruhparwar
- Department of Cardiac SurgeryHeidelberg University HospitalHeidelbergGermany
| | - Bastian Schmack
- Department of Cardiac SurgeryHeidelberg University HospitalHeidelbergGermany
| | - Fabrice F. Darche
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
- Heidelberg Center for Heart Rhythm Disorders (HCR)Heidelberg University HospitalHeidelbergGermany
| | - Dierk Thomas
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
- Heidelberg Center for Heart Rhythm Disorders (HCR)Heidelberg University HospitalHeidelbergGermany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/MannheimHeidelbergGermany
| | - Tom Bruckner
- Institute for Medical Biometry and InformaticsUniversity of HeidelbergHeidelbergGermany
| | - Andreas O. Doesch
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
- Department of Pneumology and OncologyAsklepios HospitalBad SalzungenGermany
| | - Hugo A. Katus
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
- Heidelberg Center for Heart Rhythm Disorders (HCR)Heidelberg University HospitalHeidelbergGermany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/MannheimHeidelbergGermany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and PneumologyHeidelberg University HospitalIm Neuenheimer Feld 41069120HeidelbergGermany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/MannheimHeidelbergGermany
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117
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Beale AL, Cosentino C, Segan L, Mariani JA, Vizi D, Evans S, Nanayakkara S, Kaye DM. The effect of parity on exercise physiology in women with heart failure with preserved ejection fraction. ESC Heart Fail 2020; 7:213-222. [PMID: 31960599 PMCID: PMC7083419 DOI: 10.1002/ehf2.12557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/01/2019] [Accepted: 10/25/2019] [Indexed: 01/08/2023] Open
Abstract
Aims Women are overrepresented amongst patients with heart failure with preserved ejection fraction (HFpEF); however, the underpinning mechanism for this asymmetric distribution is unclear. Pregnancy represents a potential gender‐specific risk factor for HFpEF. It leads to significant physiological adaption, and increasing parity has been associated with some cardiovascular risk. We sought to examine the relationship between prior parity with the rest and exercise haemodynamic and echocardiographic profile of women with HFpEF. Methods and results Patients referred for assessment of exertional dyspnoea and confirmed to have a haemodynamic and clinical profile consistent with HFpEF were included. Detailed evaluation consisted of rest and exercise right heart catheterization and echocardiography. A socio‐economic and obstetric history was also documented. Fifty‐eight women were assessed and categorized as having either 0–2 births or ≥3 births, dividing the cohort equally. Women with ≥3 births achieved a lower symptom‐limited workload than those with 0–2 births [38 (24–51) vs. 46 (31–68) W, P = 0.04]. Women with ≥3 births had a greater rise in pulmonary capillary wedge pressure indexed to workload with exercise [0.5 (0.3–0.8) vs. 0.3 (0.2–0.5) mmHg/W, P = 0.03], paralleled by a greater rise in right atrial pressure [10 (8–12) vs. 7 (3–11), P = 0.01]. Pulmonary vascular resistance was also higher in women with ≥3 births [1.9 (1.6–2.4) vs. 1.6 (1.4–1.9) mmHg/L/min rest, P = 0.046, and 1.9 (2.4–2.4) vs. 1.4 (1–1.8) mmHg/L/min exercise, P = 0.024]. Left ventricular ejection fraction was lower at rest [60 (57–61) vs. 63 (60–66), P = 0.008] and during exercise [65 (62–67) vs. 68 (66–70), P = 0.038] in women with higher parity. Conclusions Higher parity is associated with greater impairments in multiple physiologic parameters of HFpEF severity in women, including diastolic reserve, pulmonary vascular resistance, and systolic dysfunction.
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Affiliation(s)
- Anna L Beale
- Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Carmela Cosentino
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Louise Segan
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Justin A Mariani
- Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Donna Vizi
- Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Shona Evans
- Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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118
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Abstract
The syndrome of heart failure (HF) with preserved ejection fraction (HFpEF) is now recognized to account for up to half of HF cases and is the dominant form of HF in older adults, especially women. Multiple factors conspire in this predilection of HFpEF for older women. This review will discuss the epidemiology, pathophysiology, prognosis, and treatment of HFpEF with emphasis on the similarities and differences in cardiovascular aging changes, and the differential impact of comorbidities in women versus men. Responses to pharmacologic and lifestyle interventions are also reviewed. We conclude by suggesting future directions for both prevention and treatment of this common and highly morbid cardiovascular disorder.
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119
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Obokata M, Reddy YNV, Borlaug BA. Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: Understanding Mechanisms by Using Noninvasive Methods. JACC Cardiovasc Imaging 2020; 13:245-257. [PMID: 31202759 PMCID: PMC6899218 DOI: 10.1016/j.jcmg.2018.12.034] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022]
Abstract
Research in the last decade has substantially advanced our understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF). However, treatment options remain limited as clinical trials have largely failed to identify effective therapies. Part of this failure may be related to mechanistic heterogeneity. It is speculated that categorizing HFpEF patients based upon underlying pathophysiological phenotypes may represent the key next step in delivering the right therapies to the right patients. Echocardiography may provide valuable insight into both the pathophysiology and underlying phenotypes in HFpEF. Echocardiography also plays a key role in the evaluation of patients with unexplained dyspnea, where HFpEF is suspected but the diagnosis remains unknown. The combination of the E/e' ratio and right ventricular systolic pressure has recently been shown to add independent value to the diagnostic evaluation of patients suspected of having HFpEF. Finally, echocardiography enables identification of the different causes that mimic HFpEF but are treated differently, such as valvular heart disease, pericardial constriction, and high-output heart failure or infiltrative myopathies such as cardiac amyloid. This review summarizes the current understanding of the pathophysiology and phenotyping of HFpEF with particular attention to the role of echocardiography in this context.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota.
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120
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Reddy YNV, Obokata M, Koepp KE, Egbe AC, Wiley B, Borlaug BA. The β-Adrenergic Agonist Albuterol Improves Pulmonary Vascular Reserve in Heart Failure With Preserved Ejection Fraction. Circ Res 2019; 124:306-314. [PMID: 30582447 DOI: 10.1161/circresaha.118.313832] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
RATIONALE Pulmonary vascular resistance fails to decrease appropriately during exercise in patients with heart failure with preserved ejection fraction (HFpEF). Interventions that enhance pulmonary vasodilation might be beneficial in this cohort but could also worsen left atrial hypertension, exacerbating lung congestion. Intravenous β-agonists reduce pulmonary vascular resistance but are not suitable for chronic use. OBJECTIVE We hypothesized that the inhaled β-adrenergic agonist albuterol would improve pulmonary vasodilation during exercise in patients with HFpEF, without increasing left heart filling pressures. METHODS AND RESULTS We performed a randomized, double-blind, placebo-controlled trial testing the effects of inhaled albuterol on resting and exercise hemodynamics in subjects with HFpEF using high-fidelity micromanometer catheters and expired gas analysis. The primary end point was pulmonary vascular resistance during exercise. Subjects with HFpEF (n=30) underwent resting and exercise hemodynamic assessment and were then randomized 1:1 to inhaled, nebulized albuterol or placebo. Rest and exercise hemodynamic testing was then repeated. Albuterol improved the primary end point of exercise pulmonary vascular resistance as compared with placebo (-0.6±0.5 versus +0.1±0.7 WU; P=0.003). Albuterol enhanced cardiac output reserve and right ventricular pulmonary artery coupling, reduced right atrial and pulmonary artery pressures, improved pulmonary artery compliance, and enhanced left ventricular transmural distending pressure (all P <0.01), with no increase in pulmonary capillary hydrostatic pressures. CONCLUSIONS Albuterol improves pulmonary vascular reserve in patients with HFpEF without worsening left heart congestion. Further study is warranted to evaluate the chronic efficacy of β-agonists in HFpEF and other forms of pulmonary hypertension. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT02885636.
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Affiliation(s)
- Yogesh N V Reddy
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Masaru Obokata
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Katlyn E Koepp
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alexander C Egbe
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Brandon Wiley
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- From the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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121
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Effects of Interatrial Shunt on Pulmonary Vascular Function in Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol 2019; 74:2539-2550. [DOI: 10.1016/j.jacc.2019.08.1062] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/17/2022]
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122
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Rosenkranz S, Kramer T, Gerhardt F, Opitz C, Olsson KM, Hoeper MM. Pulmonary hypertension in HFpEF and HFrEF: Pathophysiology, diagnosis, treatment approaches. Herz 2019; 44:483-490. [PMID: 31317203 DOI: 10.1007/s00059-019-4831-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary hypertension (PH) is a frequent hemodynamic condition that is highly prevalent in patients with heart failure and reduced (HFrEF) or preserved ejection fraction (HFpEF). Irrespective of left ventricular EF, the presence of PH and right ventricular (RV) dysfunction are highly relevant for morbidity and mortality in patients with heart failure. While elevated left-sided filling pressures and functional mitral regurgitation primarily lead to post-capillary PH, current guidelines and recommendations distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH), the latter being defined by a pulmonary vascular resistance (PVR) of ≥3 Wood units. Here, we describe the pathophysiology and clinical relevance of these distinct entities, and report on the diagnostic work-up including remote pulmonary artery pressure (PAP) monitoring. Furthermore, we highlight strategies to manage PH and improve RV function in heart failure, which may include optimized management of HFrEF and HFpEF (medical and interventional), sufficient volume control, catheter-based mitral valve repair, and-in selected cases-targeted PH therapy. In this context, we also highlight gaps in evidence and the need for further research.
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Affiliation(s)
- S Rosenkranz
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany.
| | - T Kramer
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - F Gerhardt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - C Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK-Kliniken Berlin, Berlin, Germany
| | - K M Olsson
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - M M Hoeper
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
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Tichelbäcker T, Dumitrescu D, Gerhardt F, Stern D, Wissmüller M, Adam M, Schmidt T, Frerker C, Pfister R, Halbach M, Baldus S, Rosenkranz S. Pulmonary hypertension and valvular heart disease. Herz 2019; 44:491-501. [PMID: 31312873 DOI: 10.1007/s00059-019-4823-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. A specific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as a primary condition or as a consequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.
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Affiliation(s)
- T Tichelbäcker
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Dumitrescu
- Klinik für Allgemeine und Interventionelle Kardiologie, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
| | - F Gerhardt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - D Stern
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Wissmüller
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Adam
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - T Schmidt
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - C Frerker
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - R Pfister
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - M Halbach
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Baldus
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany
| | - S Rosenkranz
- Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum, Universitätsklinik Köln, Kerpener Str. 62, 50937, Cologne, Germany.
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124
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Simon MA, Nouraie M, Gladwin MT. Left Ventricular Ejection Fraction Cut Point of 50% for Heart Failure With Preserved Ejection Fraction-Reply. JAMA Cardiol 2019; 3:1023-1024. [PMID: 30027277 DOI: 10.1001/jamacardio.2018.1936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Marc A Simon
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Mehdi Nouraie
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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125
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Nitsche C, Kammerlander AA, Binder C, Duca F, Aschauer S, Koschutnik M, Snidat A, Beitzke D, Loewe C, Bonderman D, Hengstenberg C, Mascherbauer J. Native T1 time of right ventricular insertion points by cardiac magnetic resonance: relation with invasive haemodynamics and outcome in heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2019; 21:683-691. [DOI: 10.1093/ehjci/jez221] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/04/2019] [Accepted: 08/21/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
Increased afterload to the right ventricle (RV) has been shown to induce myocardial fibrosis at the RV insertion points (RVIPs). Such changes can be discrete but potentially detected by cardiac magnetic resonance (CMR) T1-mapping. Whether RVIP fibrosis is associated with prognosis in heart failure with preserved ejection fraction (HFpEF) is unknown.
Methods and results
We prospectively investigated 167 consecutive HFpEF patients, a population frequently suffering from post-capillary pulmonary hypertension, who underwent CMR including T1-mapping. About 92.8% also underwent right heart catheterization for haemodynamic assessment.
Native T1 times were 995 ± 73 ms at the anterior and 1040 ± 90 ms at the inferior RVIP. By Spearman’s rank order testing, RVIP T1 times were significantly correlated with pulmonary artery pressure (mean PAP, r = 0.313 and 0.311 for anterior and inferior RVIP), pulmonary artery wedge pressure (r = 0.301 and 0.251) and right atrial pressure (r = 0.245 and 0.185; P for all <0.05). During a mean follow-up of 43.2 ± 22.6 months, 30 (18.0%) subjects died. By multivariable Cox regression, NTproBNP [Hazard ratio (HR) 2.105, 95% confidence interval (CI) 1.332–3.328; P = 0.001], systolic PAP (HR 1.618, 95% CI 1.175–2.230; P = 0.003), and native T1 time of the anterior RVIP (HR 1.659, 95% CI 1.125–2.445; P = 0.011) were significantly associated with outcome. Also, by Kaplan–Meier analysis, T1 times at the anterior RVIPs had a significant effect on survival (log-rank, P = 0.002).
Conclusion
Interstitial expansion of the anterior RVIP as detected by CMR T1-mapping reflects haemodynamic alterations, and is independently related with prognosis in HFpEF.
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Affiliation(s)
- Christian Nitsche
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Andreas A Kammerlander
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Christina Binder
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Franz Duca
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Stefan Aschauer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Amir Snidat
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Dietrich Beitzke
- Department of Biomedical Imaging and Image guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Diana Bonderman
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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126
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Prognostic value and diagnostic properties of the diastolic pulmonary pressure gradient in patients with pulmonary hypertension and left heart disease. Int J Cardiol 2019; 290:138-143. [DOI: 10.1016/j.ijcard.2019.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/20/2019] [Accepted: 05/05/2019] [Indexed: 11/17/2022]
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127
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Abstract
In early 2019, the 6th World Symposium on Pulmonary Hypertension (WSPH) released an updated document highlighting the advances in the last five years. During the quinquennial event many experts worked together to suggest new changes in the disease diagnosis and management. Since inception of the WSPH in 1973, this is the first time when the hemodynamic definition of pulmonary hypertension (PH) has been updated. These proceedings have re-defined the different hemodynamic types of PH that occur with the left heart disease along with introduction to the genetic testing as part of pulmonary arterial hypertension (PAH) evaluation. Objective of this review is to highlight the evaluation and diagnosis of PAH based on the proceedings of the 6th WSPH. Accurate early diagnosis and subsequent management of PH is necessary, as despite of treatment advances, survival remains suboptimal.
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Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
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128
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Simon MA, Maron BA. Pulmonary Hypertension in Patients with Heart Failure with Preserved Ejection Fraction. Where to Draw the Line. Am J Respir Crit Care Med 2019; 200:278-279. [PMID: 31038986 PMCID: PMC6680312 DOI: 10.1164/rccm.201903-0689ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Marc A Simon
- 1Department of Medicine
- 2Pittsburgh Heart, Lung, Blood and Vascular Medicine InstituteUniversity of PittsburghPittsburgh, Pennsylvania
- 3UPMCPittsburgh, Pennsylvania
| | - Bradley A Maron
- 4Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBoston, Massachusettsand
- 5Department of CardiologyBoston Veterans Affairs Healthcare SystemBoston, Massachusetts
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129
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Muslem R, Ong CS, Tomashitis B, Schultz J, Ramu B, Craig ML, Van Bakel AB, Gilotra NA, Sharma K, Hsu S, Whitman GJ, Leary PJ, Cogswell R, Lozonschi L, Houston BA, Zijlstra F, Caliskan K, Bogers AJ, Tedford RJ. Pulmonary Arterial Elastance and INTERMACS-Defined Right Heart Failure Following Left Ventricular Assist Device. Circ Heart Fail 2019; 12:e005923. [DOI: 10.1161/circheartfailure.119.005923] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background:
Acute right heart failure (RHF) after left ventricular assist device implantation remains a major source of morbidity and mortality, yet the definition of RHF and the preimplant variables that predict RHF remain controversial. This study evaluated the ability of (1) INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) RHF classification to predict post-left ventricular assist device survival and (2) preoperative characteristics and hemodynamic parameters to predict severe and severe acute RHF.
Methods and Results:
An international, multicenter study at 4 large academic centers was conducted between 2008 and 2016. All subjects with hemodynamics measured by right heart catheterization within 30 days before left ventricular assist device implantation were included. RHF was defined using the INTERMACS definition for RHF. In total, 375 subjects were included (mean age, 57.4±13.2 years, 54% bridge-to-transplant). Mild RHF was most common (34%), followed by moderate RHF (16%), severe RHF (13%), and severe acute RHF (9%). Estimated on-device survival rates at 2 years were 72%, 71%, and 55% in the patients with none, mild-to-moderate, and severe-to-severe acute RHF, respectively (
P
=0.004). In addition, the independent hazard ratio for mortality was only increased in the patients with severe-to-severe acute RHF (hazard ratio, 3.95; 95% CI, 2.16–7.23;
P
<0.001). INTERMACS-defined RHF was superior to postimplant inotrope duration alone in the prediction of all-cause mortality. In multivariable analysis, older age, lower INTERMACS classes, and higher pulmonary arterial elastance (ratio of systolic pulmonary artery pressure to stroke volume) before left ventricular assist device, were identified as significant predictors of severe-to-severe acute RHF. Stratifying patients by ratio of systolic pulmonary artery pressure to stroke volume and right atrial pressure significantly improved the discrimination between patients at risk for severe-to-severe acute RHF.
Conclusions:
The INTERMACS RHF classification correctly identifies patients at risk for mortality, though this risk is only increased in patients with severe-to-severe acute RHF. Several predictors for RHF were identified, of which ratio of systolic pulmonary artery pressure to stroke volume was the strongest hemodynamic predictor. Coupling ratio of systolic pulmonary artery pressure to stroke volume with right atrial pressure may be most helpful in identifying patients at risk for severe-to-severe acute RHF.
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Affiliation(s)
- Rahatullah Muslem
- Department of Cardiology (R.M., F.Z., K.C.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Chin S. Ong
- Department of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD (C.S.O., G.L.W.)
| | - Brett Tomashitis
- Division of Cardiology, Department of Medicine (B.T., B.R., M.L.C., A.B.V.B., B.A.H., R.J.T.), Medical University of South Carolina, Charleston
| | - Jessica Schultz
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis (J.S., R.C.)
| | - Bhavadharini Ramu
- Division of Cardiology, Department of Medicine (B.T., B.R., M.L.C., A.B.V.B., B.A.H., R.J.T.), Medical University of South Carolina, Charleston
| | - Michael L. Craig
- Division of Cardiology, Department of Medicine (B.T., B.R., M.L.C., A.B.V.B., B.A.H., R.J.T.), Medical University of South Carolina, Charleston
| | - Adrian B. Van Bakel
- Division of Cardiology, Department of Medicine (B.T., B.R., M.L.C., A.B.V.B., B.A.H., R.J.T.), Medical University of South Carolina, Charleston
| | - Nisha A. Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (N.A.G., K.S., S.H.)
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (N.A.G., K.S., S.H.)
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (N.A.G., K.S., S.H.)
| | - Glenn J. Whitman
- Department of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD (C.S.O., G.L.W.)
| | - Peter J. Leary
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle (P.J.L.)
| | - Rebecca Cogswell
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis (J.S., R.C.)
| | - Lucian Lozonschi
- Department of Cardiothoracic Surgery (L.L.), Medical University of South Carolina, Charleston
| | - Brian A. Houston
- Division of Cardiology, Department of Medicine (B.T., B.R., M.L.C., A.B.V.B., B.A.H., R.J.T.), Medical University of South Carolina, Charleston
| | - Felix Zijlstra
- Department of Cardiology (R.M., F.Z., K.C.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Kadir Caliskan
- Department of Cardiology (R.M., F.Z., K.C.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic Surgery (A.J.J.C.B.), Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine (B.T., B.R., M.L.C., A.B.V.B., B.A.H., R.J.T.), Medical University of South Carolina, Charleston
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130
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Condon DF, Nickel NP, Anderson R, Mirza S, de Jesus Perez VA. The 6th World Symposium on Pulmonary Hypertension: what's old is new. F1000Res 2019; 8. [PMID: 31249672 PMCID: PMC6584967 DOI: 10.12688/f1000research.18811.1] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 12/24/2022] Open
Abstract
In February 2018, the 6th World Symposium on Pulmonary Hypertension (WSPH) brought together experts from various disciplines to review the most relevant clinical and scientific advances in the field of PH over the last 5 years. Based on careful review and discussions by members of the different task forces, major revisions were made on the hemodynamic definition for various forms of PH and new genes were added to the list of genetic markers associated with pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease. In addition, the use of risk stratification tools was encouraged as a strategy to reduce one-year mortality risk in PAH patients through early implementation of PAH therapies. While members of the medical community are still debating some of the proposed changes, the new WSPH guidelines advocate early diagnosis and initiation of combination therapy to reduce mortality and improve quality of life in patients with PH.
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Affiliation(s)
- David F Condon
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Ryan Anderson
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA
| | - Shireen Mirza
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA.,Vera Moulton Wall Center for Pulmonary Vascular Research, Stanford University, Stanford, USA
| | - Vinicio A de Jesus Perez
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, USA.,Vera Moulton Wall Center for Pulmonary Vascular Research, Stanford University, Stanford, USA
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131
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Abstract
Approximately half of the patients with signs and symptoms of heart failure have a left ventricular ejection fraction that is not markedly abnormal. Despite the historically initial surprise, heightened risks for heart failure specific major adverse events occur across the broad range of ejection fraction, including normal. The recognition of the magnitude of the problem of heart failure with preserved ejection fraction in the past 20 years has spurred an explosion of clinical investigation and growing intensity of informative outcome trials. This article addresses the historic development of this component of the heart failure syndrome, including the epidemiology, pathophysiology, and existing and planned therapeutic studies. Looking forward, more specific phenotyping and even genotyping of subpopulations should lead to improvements in outcomes from future trials.
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Affiliation(s)
- Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amil M. Shah
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry A. Borlaug
- Cardiovascular Medicine Division, Mayo Clinic, Rochester, Minnesota
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132
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Levine AR, Simon MA, Gladwin MT. Pulmonary vascular disease in the setting of heart failure with preserved ejection fraction. Trends Cardiovasc Med 2019; 29:207-217. [PMID: 30177249 PMCID: PMC6378124 DOI: 10.1016/j.tcm.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/12/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is defined as clinical features of heart failure, ideally with biomarker evidence such as elevated plasma natriuretic peptide levels, in the setting of an ejection fraction (EF) greater than 50% and imaging evidence of diastolic left ventricular dysfunction [1,2]. In the absence of cardiac imaging or invasive hemodynamics, this is a clinical syndrome that is often indistinguishable from heart failure with reduced ejection fraction (HFrEF). HFpEF and HFrEF present with a cadre of comparable signs and symptoms including jugular venous distention, pulmonary rales on auscultation, breathlessness, orthopnea, exercise intolerance, exertional dyspnea, fatigue and peripheral edema. HFpEF accounts for at least half of all diagnoses of heart failure [1,2]. Pulmonary hypertension (PH) is a common complication of HFpEF that is linked to worse disease morbidity and mortality. In fact, mortality has been linked to increases in the intrinsic pulmonary vascular resistance in the setting of increased left ventricular end diastolic pressure, characterized hemodynamically by rises in the transpulmonary pressure gradient, pulmonary vascular resistance or diastolic pressure gradient. Despite being the most common form of PH, there are no approved therapies for the treatment of PH secondary to HFpEF. This review will summarize the hemodynamic classifications of PH in the setting of HFpEF, mechanisms of disease, the potential contribution of pulmonary vascular disease to poor outcomes in patients with HFpEF, and new approaches to therapy.
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Affiliation(s)
- Andrea R Levine
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Marc A Simon
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; University of Pittsburgh Medical Center Heart and Vascular Institute Pittsburgh, Pittsburgh, PA 15213, United States; University of Pittsburgh Department of Bioengineering Pittsburgh, Pittsburgh, PA 15213, United States
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, United States; Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States.
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133
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Estephan LE, Genuardi MV, Kosanovich CM, Risbano MG, Zhang Y, Petro N, Watson A, Al Aaraj Y, Sembrat JC, Rojas M, Goncharov DA, Simon MA, Goncharova EA, Vaidya A, Smith A, Mazurek J, Han Y, Chan SY. Distinct plasma gradients of microRNA-204 in the pulmonary circulation of patients suffering from WHO Groups I and II pulmonary hypertension. Pulm Circ 2019; 9:2045894019840646. [PMID: 30854934 PMCID: PMC6440051 DOI: 10.1177/2045894019840646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pulmonary hypertension (PH), a heterogeneous vascular disease, consists of subtypes with overlapping clinical phenotypes. MicroRNAs, small non-coding RNAs that negatively regulate gene expression, have emerged as regulators of PH pathogenesis. The muscle-specific micro RNA (miR)-204 is known to be depleted in diseased pulmonary artery smooth muscle cells (PASMCs), furthering proliferation and promoting PH. Alterations of circulating plasma miR-204 across the trans-pulmonary vascular bed might provide mechanistic insights into the observed intracellular depletion and may help distinguish PH subtypes. MiR-204 levels were quantified at sequential pulmonary vasculature sites in 91 patients with World Health Organization (WHO) Group I pulmonary arterial hypertension (PAH) (n = 47), Group II PH (n = 22), or no PH (n = 22). Blood from the right atrium/superior vena cava, pulmonary artery, and pulmonary capillary wedge was collected. Peripheral blood mononuclear cells (PBMCs) were isolated (n = 5/group). Excretion of miR-204 by PAH-PASMCs was also quantified in vitro. In Group I patients only, miR-204 concentration increased sequentially along the pulmonary vasculature (log fold-change slope = 0.22 [95% CI = 0.06–0.37], P = 0.008). PBMCs revealed insignificant miR-204 variations among PH groups (P = 0.12). Cultured PAH-PAMSCs displayed a decrease of intracellular miR-204 (P = 0.0004), and a converse increase of extracellular miR-204 (P = 0.0018) versus control. The stepwise elevation of circulating miR-204 across the pulmonary vasculature in Group I, but not Group II, PH indicates differences in muscle-specific pathobiology between subtypes. Considering the known importance of miR-204 in PH, these findings may suggest pathologic excretion of miR-204 in Group I PAH by PASMCs, thereby accounting for decreased intracellular miR-204 concentration.
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Affiliation(s)
- Leonard E Estephan
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael V Genuardi
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,2 Division of Cardiology, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Chad M Kosanovich
- 2 Division of Cardiology, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael G Risbano
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yingze Zhang
- 3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nancy Petro
- 3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Annie Watson
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yassmin Al Aaraj
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John C Sembrat
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mauricio Rojas
- 3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dmitry A Goncharov
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marc A Simon
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Elena A Goncharova
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,3 Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anjali Vaidya
- 4 Division of Cardiovascular Medicine, Temple University Health Systems, Philadelphia, PA, USA
| | - Akaya Smith
- 5 Division of Pulmonary Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy Mazurek
- 6 Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yuchi Han
- 6 Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen Y Chan
- 1 Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,2 Division of Cardiology, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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134
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Vachiéry JL, Tedford RJ, Rosenkranz S, Palazzini M, Lang I, Guazzi M, Coghlan G, Chazova I, De Marco T. Pulmonary hypertension due to left heart disease. Eur Respir J 2019; 53:13993003.01897-2018. [PMID: 30545974 PMCID: PMC6351334 DOI: 10.1183/13993003.01897-2018] [Citation(s) in RCA: 356] [Impact Index Per Article: 71.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 12/22/2022]
Abstract
Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past 5 years since the 5th World Symposium on Pulmonary Hypertension in 2013, leading to a better understanding of PH-LHD, challenges and gaps in evidence. PH in heart failure with preserved ejection fraction represents the most complex situation, as it may be misdiagnosed with group 1 PH. Based on the latest evidence, we propose a new haemodynamic definition for PH due to LHD and a three-step pragmatic approach to differential diagnosis. This includes the identification of a specific “left heart” phenotype and a non-invasive probability of PH-LHD. Invasive confirmation of PH-LHD is based on the accurate measurement of pulmonary arterial wedge pressure and, in patients with high probability, provocative testing to clarify the diagnosis. Finally, recent clinical trials did not demonstrate a benefit in treating PH due to LHD with pulmonary arterial hypertension-approved therapies. State of the art and research perspectives in pulmonary hypertension due to left heart disease including diagnostic and treatment insightshttp://ow.ly/vr0I30md6KC
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Affiliation(s)
- Jean-Luc Vachiéry
- Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Ryan J Tedford
- Division of Cardiology, Dept of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Dept of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | | | - Irene Lang
- Dept of Cardiology, AKH-Vienna, Medical University of Vienna, Vienna, Austria
| | - Marco Guazzi
- Dept of Biomedical Sciences for Health, University of Milan and Dept of Cardiology University, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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135
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Therapeutic potential of phosphodiesterase type 5 inhibitors in heart failure with preserved ejection fraction and combined post- and pre-capillary pulmonary hypertension. Int J Cardiol 2019; 283:152-158. [PMID: 30777406 DOI: 10.1016/j.ijcard.2018.12.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/04/2018] [Accepted: 12/28/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Heart failure with preserved ejection fraction (HFpEF) is frequently associated with pulmonary hypertension (PH), which substantially impacts survival. Based on pulmonary vascular resistance (PVR) and the diastolic pressure gradient (DPG), current guidelines distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH). However, the therapeutic consequences of this sub-classification remain entirely unclear. We specifically investigated the efficacy and safety of PDE5i in patients with HFpEF and CpcPH. METHODS In 40 hemodynamically precisely characterized patients with HFpEF and Cpc-PH who were treated with a PDE5i for at least 12 months, the therapeutic effect on 6-minute walk distance (6MWD), WHO functional class (FC), NTproBNP levels, right ventricular function, and hospitalization rates was evaluated. RESULTS Patients' mean age was 73 ± 9 years, and comorbidities were frequent (78% hypertension, 58% atrial fibrillation, 35% diabetes). Initially, 38 patients (95%) were in WHO-FC III and 2 patients (5%) in WHO-FC II. Prior to PDE5i initiation, mean PAPm was 46.2 ± 10.3 mmHg, PAWP 21.2 ± 4.7 mmHg, DPG 5.5 ± 7.2 mmHg, and PVR 6.2 ± 3.0 WU. After 12 months of PDE5i therapy, the 6MWD increased from initially 277 ± 17 to 340 ± 18 m (p < 0.001), and the proportion of patients in WHO-FC I/II increased from 5% to 37.5%. NTproBNP levels decreased by 33% (p = 0.004), and TAPSE improved from 16.8 ± 0.7 mm at baseline to 18.2 ± 0.6 mm (p = 0.01). The rate of HF-associated hospitalizations was substantially lower in the 12 months post PDE5i initiation compared to the prior 12 months. The DPG had no impact on the response to therapy. No deaths occurred, and typical side effects of PDE5i were observed. CONCLUSION These data indicate that at least a subset of precisely characterized patients with HFpEF and CpcPH who tolerate PDE5i may benefit from targeted therapy. A randomized study in this particular sub-population is warranted.
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Lai YC, Wang L, Gladwin MT. Insights into the pulmonary vascular complications of heart failure with preserved ejection fraction. J Physiol 2018; 597:1143-1156. [PMID: 30549058 DOI: 10.1113/jp275858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (PH-HFpEF) is a growing public health problem that is increasing in prevalence. While PH-HFpEF is defined by a high mean pulmonary artery pressure, high left ventricular end-diastolic pressure and a normal ejection fraction, some HFpEF patients develop PH in the presence of pulmonary vascular remodelling with a high transpulmonary pressure gradient or pulmonary vascular resistance. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, which include obesity, diabetes and hypertension, are recognized as risk factors for PH-HFpEF. Qualitative studies have documented that patients with PH-HFpEF develop more severe symptoms than those with HFpEF and are associated with more significant exercise intolerance, frequent hospitalizations, right heart failure and reduced survival. Currently, there are no effective therapies for PH-HFpEF, although a number of candidate drugs are being evaluated, including soluble guanylate cyclase stimulators, phosphodiesterase type 5 inhibitors, sodium nitrite and endothelin receptor antagonists. In this review we attempt to provide an updated overview of recent findings pertaining to the pulmonary vascular complications in HFpEF in terms of clinical definitions, epidemiology and pathophysiology. Mechanisms leading to pulmonary vascular remodelling in HFpEF, a summary of pre-clinical models of HFpEF and PH-HFpEF, and new candidate therapeutic strategies for the treatment of PH-HFpEF are summarized.
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Affiliation(s)
- Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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137
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Editorial commentary: Pulmonary hypertension in left heart disease: Definitions, data sources, and the road ahead. Trends Cardiovasc Med 2018; 29:218-219. [PMID: 30279040 DOI: 10.1016/j.tcm.2018.09.013] [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: 09/14/2018] [Accepted: 09/16/2018] [Indexed: 11/21/2022]
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138
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Cao TH. Left Ventricular Ejection Fraction Cut Point of 50% for Heart Failure With Preserved Ejection Fraction. JAMA Cardiol 2018; 3:1023. [PMID: 30027275 DOI: 10.1001/jamacardio.2018.1906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thong Huy Cao
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
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139
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Baruch G, Rothschild E, Kapusta L, Schwartz LA, Biner S, Aviram G, Ingbir M, Nachmany I, Keren G, Topilsky Y. Impact of right ventricular dysfunction and end-diastolic pulmonary artery pressure estimated from analysis of tricuspid regurgitant velocity spectrum in patients with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2018; 20:446-454. [DOI: 10.1093/ehjci/jey116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/05/2018] [Accepted: 07/24/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Guy Baruch
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Ehud Rothschild
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Livia Kapusta
- Department of Paediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Paediatrics, Paediatric Cardiology Unit, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lorin Arie Schwartz
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Simon Biner
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Galit Aviram
- Division of Radiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Meirav Ingbir
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Ido Nachmany
- Division of Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Gad Keren
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv, Israel
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Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:53-62. [PMID: 30527996 DOI: 10.1016/j.ijcard.2018.08.080] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 12/25/2022]
Abstract
In the summer of 2016, delegates from the German Society of Cardiology (DGK), the German Respiratory Society (DGP), and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH associated with left heart disease. In this context, the European Guidelines point out that the drugs currently approved to treat patients with PAH (prostanoids, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, sGC stimulators) have not sufficiently been investigated in other forms of PH. However, despite the lack of respective efficacy data, an uncritical use of targeted PAH drugs in patients with PH associated with left heart disease is currently observed at an increasing rate. This development is a matter of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease. In that sense, the distinction between isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH) and their proper definition may be of particular relevance. The detailed results and recommendations of the working group on PH associated with left heart disease, which were last updated in the spring of 2018, are summarized in this article.
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