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Eisman AS, Shah RV, Dhakal BP, Pappagianopoulos PP, Wooster L, Bailey C, Cunningham TF, Hardin KM, Baggish AL, Ho JE, Malhotra R, Lewis GD. Pulmonary Capillary Wedge Pressure Patterns During Exercise Predict Exercise Capacity and Incident Heart Failure. Circ Heart Fail 2019; 11:e004750. [PMID: 29695381 DOI: 10.1161/circheartfailure.117.004750] [Citation(s) in RCA: 150] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/22/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Single measurements of left ventricular filling pressure at rest lack sensitivity for identifying heart failure with preserved ejection fraction (HFpEF) in patients with dyspnea on exertion. We hypothesized that exercise hemodynamic measurements (ie, changes in pulmonary capillary wedge pressure [PCWP] indexed to cardiac output [CO]) may more sensitively differentiate HFpEF and non-HFpEF disease states, reflect aerobic capacity, and forecast heart failure outcomes in individuals with normal PCWP at rest. METHODS AND RESULTS We studied 175 patients referred for cardiopulmonary exercise testing with hemodynamic monitoring: controls (n=33), HFpEF with resting PCWP≥15 mm Hg (n=32), and patients with dyspnea on exertion with normal resting PCWP and left ventricular ejection fraction (DOE-nlrW; n=110). Across 1835 paired PCWP-CO measurements throughout exercise, we used regression techniques to define normative bounds of "PCWP/CO slope" in controls and tested the association of PCWP/CO slope with exercise capacity and composite cardiac outcomes (defined as cardiac death, incident resting PCWP elevation, or heart failure hospitalization) in the DOE-nlrW group. Relative to controls (PCWP/CO slope, 1.2±0.4 mm Hg/L/min), patients with HFpEF had a PCWP/CO slope of 3.4±1.9 mm Hg/L/min. We used a threshold (2 SD above the mean in controls) of 2 mm Hg/L/min to define abnormal. PCWP/CO slope >2 in DOE-nlrW patients was common (n=45/110) and was associated with reduced peak Vo2 (P<0.001) and adverse cardiac outcomes after adjustment for age, sex, and body mass index (hazard ratio, 3.47; P=0.03) at a median 5.3-year follow-up. CONCLUSIONS Elevated PCWP/CO slope during exercise (>2 mm Hg/L/min) is common in DOE-nlrW and predicts exercise capacity and heart failure outcomes. These findings suggest that current definitions of HFpEF based on single measures during rest are insufficient and that assessment of exercise PCWP/CO slope may refine early HFpEF diagnosis.
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Affiliation(s)
- Aaron S Eisman
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ravi V Shah
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Bishnu P Dhakal
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Paul P Pappagianopoulos
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Luke Wooster
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Cole Bailey
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Thomas F Cunningham
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kathryn M Hardin
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Aaron L Baggish
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jennifer E Ho
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Rajeev Malhotra
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Gregory D Lewis
- Cardiology Division and the Pulmonary and Critical Care Unit of the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.
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152
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Artificial Intelligence Transforms the Future of Health Care. Am J Med 2019; 132:795-801. [PMID: 30710543 PMCID: PMC6669105 DOI: 10.1016/j.amjmed.2019.01.017] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 02/06/2023]
Abstract
Life sciences researchers using artificial intelligence (AI) are under pressure to innovate faster than ever. Large, multilevel, and integrated data sets offer the promise of unlocking novel insights and accelerating breakthroughs. Although more data are available than ever, only a fraction is being curated, integrated, understood, and analyzed. AI focuses on how computers learn from data and mimic human thought processes. AI increases learning capacity and provides decision support system at scales that are transforming the future of health care. This article is a review of applications for machine learning in health care with a focus on clinical, translational, and public health applications with an overview of the important role of privacy, data sharing, and genetic information.
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153
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Roberts TJ, Burns AT, MacIsaac RJ, MacIsaac AI, Prior DL, La Gerche A. Sildenafil enhances central hemodynamic responses to exercise, but not V̇o 2peak, in people with diabetes mellitus. J Appl Physiol (1985) 2019; 127:1-10. [PMID: 31046521 PMCID: PMC6692740 DOI: 10.1152/japplphysiol.00947.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 11/22/2022] Open
Abstract
Exercise capacity is frequently reduced in people with diabetes mellitus (DM), and the contribution of pulmonary microvascular dysfunction remains undefined. We hypothesized that pulmonary microvascular disease, measured by a novel exercise echocardiography technique termed pulmonary transit of agitated contrast (PTAC), would be greater in subjects with DM and that the use of pulmonary vasodilator agent sildenafil would improve exercise performance by reducing right ventricular afterload. Forty subjects with DM and 20 matched controls performed cardiopulmonary exercise testing and semisupine exercise echocardiography 1 h after placebo or sildenafil ingestion in a double-blind randomized crossover design. The primary efficacy end point was exercise capacity (V̇o2peak) while secondary measures included pulmonary vascular resistance, cardiac output, and change in PTAC. DM subjects were aged 44 ± 13 yr, 73% male, with 16 ± 10 yr DM history. Sildenafil caused marginal improvements in echocardiographic measures of biventricular systolic function in DM subjects. Exercise-induced increases in pulmonary artery systolic pressure and pulmonary vascular resistance were attenuated with sildenafil, while heart rate (+2.4 ±1.2 beats/min, P = 0.04) and cardiac output (+322 ± 21 ml, P = 0.03) improved. However, the degree of PTAC did not change (P = 0.93) and V̇o2peak did not increase following sildenafil as compared with placebo (V̇o2peak: 31.8 ± 9.7 vs. 32.1 ± 9.5 ml·min-1·kg-1, P = 0.42). We conclude that sildenafil administration causes modest acute improvements in central hemodynamics but does not improve exercise capacity. This may be due to the mismatch in action of sildenafil on the pulmonary arteries rather than the distal pulmonary microvasculature and potential adverse effects on peripheral oxygen extraction. NEW & NOTEWORTHY This is one of the largest and most comprehensive studies of cardiopulmonary exercise performance in people with diabetes mellitus and to our knowledge the first to assess the effect of sildenafil using detailed echocardiographic measures during incremental exercise. Sildenafil attenuated the rise in pulmonary vascular resistance while augmenting cardiac output and intriguingly heart rate, without conferring any improvement in exercise capacity. The enhanced central hemodynamic indexes may have been offset by reduced peripheral O2 extraction.
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Affiliation(s)
- Timothy J Roberts
- Department of Cardiology, St. Vincent's Hospital Melbourne , Fitzroy , Australia
- St. Vincent's Department of Medicine, University of Melbourne , Fitzroy , Australia
| | - Andrew T Burns
- Department of Cardiology, St. Vincent's Hospital Melbourne , Fitzroy , Australia
- St. Vincent's Department of Medicine, University of Melbourne , Fitzroy , Australia
| | - Richard J MacIsaac
- St. Vincent's Department of Medicine, University of Melbourne , Fitzroy , Australia
- Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Fitzroy , Australia
| | - Andrew I MacIsaac
- Department of Cardiology, St. Vincent's Hospital Melbourne , Fitzroy , Australia
- St. Vincent's Department of Medicine, University of Melbourne , Fitzroy , Australia
| | - David L Prior
- Department of Cardiology, St. Vincent's Hospital Melbourne , Fitzroy , Australia
- St. Vincent's Department of Medicine, University of Melbourne , Fitzroy , Australia
- National Centre for Sports Cardiology, Fitzroy , Australia
| | - André La Gerche
- Department of Cardiology, St. Vincent's Hospital Melbourne , Fitzroy , Australia
- St. Vincent's Department of Medicine, University of Melbourne , Fitzroy , Australia
- National Centre for Sports Cardiology, Fitzroy , Australia
- Baker Heart and Diabetes Institute , Melbourne , Australia
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154
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Gulati G, Grandin EW, Kennedy K, Cabezas F, DeNofrio DD, Kociol R, Rame JE, Pagani FD, Kirklin JK, Kormos RL, Teuteberg J, Kiernan M. Preimplant Phosphodiesterase-5 Inhibitor Use Is Associated With Higher Rates of Severe Early Right Heart Failure After Left Ventricular Assist Device Implantation. Circ Heart Fail 2019; 12:e005537. [PMID: 31181953 DOI: 10.1161/circheartfailure.118.005537] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Early right heart failure (RHF) occurs commonly in left ventricular assist device (LVAD) recipients, and increased right ventricular (RV) afterload may contribute. Selective pulmonary vasodilators, like phosphodiesterase-5 inhibitors (PDE5i), are used off-label to reduce RV afterload before LVAD implantation, but the association between preoperative PDE5i use and early RHF after LVAD is unknown. Methods and Results We analyzed adult patients from the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support) who received a continuous flow LVAD after 2012. Patients on PDE5i were propensity-matched 1:1 to controls. The primary outcome was the incidence of severe early RHF, defined as the composite of death from RHF within 30 days, need for RV assist device support within 30 days, or use of inotropes beyond 14 days. Of 11 544 continuous flow LVAD recipients, 1199 (10.4%) received preoperative PDE5i. Compared to controls, patients on PDE5i had higher pulmonary artery systolic pressure (53.4 mm Hg versus 49.5 mm Hg) and pulmonary vascular resistance (2.6 WU versus 2.3 WU; P<0.001 for both). Before propensity matching, the incidence of severe early RHF was higher among patients on PDE5i than in controls (29.4% versus 23.1%; unadjusted odds ratio (OR), 1.32; 95% CI, 1.17-1.50). This association persisted after propensity matching (PDE5i, 28.9% versus control 23.7%; OR, 1.31; 95% CI, 1.09-1.57), driven by a higher incidence of prolonged inotropic support. Similar results were observed across a wide range of subgroups stratified by markers of pulmonary vascular disease and RV dysfunction. Conclusions Patients treated with preoperative PDE5i had markers of increased RV afterload and HF severity compared to unmatched controls. Even after propensity matching, patients receiving preimplant PDE5i therapy had higher rates of post-LVAD RHF.
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Affiliation(s)
- Gaurav Gulati
- Cardiovascular Center, Tufts Medical Center, Boston, MA (G.G., D.D.D., M.K.)
| | - E Wilson Grandin
- Cardiovascular Institute (E.W.G., F.C.).,Smith Center for Outcomes Research in Cardiology (E.W.G., K.K.)
| | - Kevin Kennedy
- Smith Center for Outcomes Research in Cardiology (E.W.G., K.K.)
| | | | - David D DeNofrio
- Cardiovascular Center, Tufts Medical Center, Boston, MA (G.G., D.D.D., M.K.)
| | - Robb Kociol
- Division of Cardiology (R.K.), Beth Israel Deaconess Medical Center, Boston, MA
| | - J Eduardo Rame
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia (J.E.R.)
| | - Francis D Pagani
- Division of Cardiothoracic Surgery, University of Michigan School of Medicine, Ann Arbor (F.D.P.)
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama Birmingham School of Medicine (J.K.K.)
| | - Robert L Kormos
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (R.L.K.)
| | - Jeffrey Teuteberg
- Cardiovascular Medicine, Stanford University Medical Center, CA (J.T.)
| | - Michael Kiernan
- Cardiovascular Center, Tufts Medical Center, Boston, MA (G.G., D.D.D., M.K.)
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155
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension (PH) frequently complicates heart failure and portends a worse prognosis. This review will summarize and discuss recent updates in the classification and management of patients with PH due to left heart disease. RECENT FINDINGS Careful hemodynamic assessment is critical to the classification of patients with PH and heart failure. Two hemodynamic subgroups of PH in heart failure patients have been described: isolated post-capillary pulmonary hypertension and combined post- and precapillary pulmonary hypertension. The cornerstone in management of PH due to left heart disease is the treatment of the underlying left heart pathology; however, ongoing trials have been designed to test pulmonary vasodilators in this cohort. PH-specific therapies have not demonstrated a benefit in patients with pulmonary hypertension due to left heart disease. Understanding the distinct pathobiology of each hemodynamic subgroup may lead to the development of useful biomarkers and effective targeted therapies.
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Affiliation(s)
- Mandar A Aras
- Division of Cardiology, University of California San Francisco, 505 Parnassus Avenue, Box 0124, San Francisco, CA, 94143, USA
| | | | - Teresa De Marco
- Division of Cardiology, University of California San Francisco, 505 Parnassus Avenue, Box 0124, San Francisco, CA, 94143, USA.
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156
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Right Ventricular Function and Sexual Function: Exploring Shadows in Male and Female Patients With Heart Failure. J Sex Med 2019; 16:1199-1211. [PMID: 31133422 DOI: 10.1016/j.jsxm.2019.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/16/2019] [Accepted: 04/20/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Sexual health plays an important role in heart failure (HF) patients, and the relationship between HF and sexual dysfunction is well established; however, the role of right ventricular function in sexual dysfunction has not been investigated sufficiently. AIM To investigate the potential association between right ventricular dysfunction and sexual dysfunction in both male and female patients with HF. METHODS Patients with a clinical diagnosis of HF were evaluated in a cross-sectional study. Patients from the whole spectrum of HF were included in the study, regardless of cause, duration, and classification of HF. Sexual function in men was evaluated with the International Index of Erectile Function and in women with the Female Sexual Functioning Index. MAIN OUTCOME MEASURES We demonstrate that right ventricular dysfunction is associated with worse sexual function in both men and women. RESULTS 306 consecutive patients with HF participated in the study. Right ventricular systolic dysfunction ranged from 24.2-39.1% and right ventricular diastolic dysfunction from 16.1-83.1%, depending on the echocardiographic parameter that was assessed. Right ventricular systolic dysfunction assessed by tricuspid annular plane systolic excursion (TAPSE), TAPSE/pulmonary artery systolic pressure ratio, and right ventricular basal diameter was associated with a lower International Index of Erectile Function score (P = .031, P = .009, and P < .001, respectively). Multiple linear regression analysis revealed that erectile function was independently associated only with TAPSE/pulmonary artery systolic pressure ratio and tricuspid late tricuspid diastolic flow velocity wave (β = 32.84, P = .006; and β = -0.47, P = .026, respectively), whereas female sexual function was independently associated only with the early tricuspid diastolic flow velocity/late tricuspid diastolic flow velocity ratio (β= -0.47, P = .026). CLINICAL IMPLICATIONS Our study demonstrates that right ventricular dysfunction in patients with HF reflects an impaired sexual function status. Physicians should be aware of this association and closely evaluate those patients for sexual dysfunction. STRENGTHS & LIMITATIONS We innovatively assessed the correlation between right ventricular dysfunction and sexual function using validated questionnaires. The main limitation is the relatively small sample size. CONCLUSIONS Our study provides some new insights into the relationship between sexual dysfunction and right ventricular systolic and diastolic dysfunction in HF patients, also suggesting potential interventions to improve sexual and right ventricular function and prognosis in this population. Koutsampasopoulos K, Vogiatzis I, Ziakas A, et al. Right Ventricular Function and Sexual Function: Exploring Shadows in Male and Female Patients With Heart Failure. J Sex Med 2019;16:1199-1211.
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157
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Abstract
Patients with heart failure (HF) syndromes have been categorized as those with reduced ejection fraction (EF) or preserved EF (HFpEF), and ischemia plays a key role in both types. HF remains a major cause of morbidity and mortality worldwide, and with the aging of our population this burden continues to rise, predominantly as a result of hospitalizations for HFpEF. Patients with obstructive coronary artery disease more likely have HF with reduced EF, rather than HFpEF, secondary to acute ischemic injury resulting in myocardial infarction, and large outcomes trials of treatments with neurohumoral inhibition have documented reduced adverse outcomes. In contrast, similar treatments in patients with HFpEF have not proven beneficial. This therapeutic dilemma may be attributed, in part, to heterogeneity in the underlying pathophysiology with different systemic and myocardial signaling pathways, despite similar clinical presentations and findings, in patients with HFpEF. Also, emerging evidence indicates that impaired myocardial perfusion and inflammation secondary to multiple comorbidities are key mechanisms in HFpEF. We will thoroughly review the role of ischemic heart disease in the pathogenesis of HF with reduced EF and HFpEF, and discuss the medical management strategies available for these conditions.
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Affiliation(s)
- Islam Y Elgendy
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville
| | - Dhruv Mahtta
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville
| | - Carl J Pepine
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville
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158
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Abstract
Introduction: Pulmonary hypertension (PH) secondary to left-sided heart disease (Group 2 PH) is a frequent complication of heart failure (HF) and is a heterogeneous phenotypic disorder that worsens exercise capacity, increases risk for hospitalization and survival independent of left ventricular ejection fraction (LVEF) or stage of HF. Areas covered: In this review, an update of the current knowledge and some potential challenges about the pathophysiology and treatments of group 2 PH in patients with HF of either preserved or reduced ejection fraction are provided. Also, this review discusses the epidemiology and provides hints for the optimal evaluation and diagnosis of these patients to prevent misclassification of their pulmonary hypertension. Expert opinion: There are many of areas lacking knowledge and understanding in the field of pulmonary hypertension associated to left heart disease (PH-LHD) that should be addressed in the future. Further research should be performed, in terms of pathobiology, and understanding the predisposition (genetic susceptibility and contributing factors) of the different phenotypes of this disorder. More clinical trials targeting new therapeutic options and specific PH therapies are warranted to help this increasing important patient group as the current guidelines recommend to only treat the underlying left-sided heart disease.
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Affiliation(s)
- Ronald Zolty
- a Medical Center College of Medicine , University of Nebraska , Omaha , NE , USA
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159
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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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160
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Sparrow CT, LaRue SJ, Schilling JD. Intersection of Pulmonary Hypertension and Right Ventricular Dysfunction in Patients on Left Ventricular Assist Device Support: Is There a Role for Pulmonary Vasodilators? Circ Heart Fail 2019; 11:e004255. [PMID: 29321132 DOI: 10.1161/circheartfailure.117.004255] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life in patients with advanced heart failure. Despite these benefits, combined post- and precapillary pulmonary hypertension can be particularly problematic in patients on LVAD support, often exacerbating right ventricular (RV) dysfunction. Both persistently elevated pulmonary vascular resistance and RV dysfunction are associated with adverse outcomes, including death after LVAD. These observations have led to significant interest in the use of pulmonary vasodilators to treat pulmonary hypertension and preserve RV function among LVAD-supported patients. Although pulmonary vasodilators are commonly used for the treatment of pulmonary hypertension and RV dysfunction in LVADs, the benefits of this practice remain unclear. The purpose of this review is to highlight the current challenges in managing pulmonary vascular disease and RV dysfunction in patients with heart failure on LVAD support.
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Affiliation(s)
- Christopher T Sparrow
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Shane J LaRue
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO
| | - Joel D Schilling
- From the Division of Cardiology, Department of Medicine (C.T.S., S.J.L., J.D.S.) and Department of Pathology and Immunology (J.D.S.), Washington University School of Medicine, St. Louis, MO.
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161
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Silverman DN, Shah SJ. Treatment of Heart Failure With Preserved Ejection Fraction (HFpEF): the Phenotype-Guided Approach. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:20. [DOI: 10.1007/s11936-019-0709-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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162
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Montero D, Haider T, Barthelmes J, Goetze JP, Cantatore S, Lundby C, Sudano I, Ruschitzka F, Flammer AJ. Age-dependent impairment of the erythropoietin response to reduced central venous pressure in HFpEF patients. Physiol Rep 2019; 7:e14021. [PMID: 30821129 PMCID: PMC6395308 DOI: 10.14814/phy2.14021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 12/22/2022] Open
Abstract
Despite growing research interest in the pathophysiology of heart failure with preserved ejection fraction (HFpEF), it remains unknown whether central hemodynamic alterations inherently present in this condition do affect blood pressure and blood volume (BV) regulation. The present study sought to determine hemodynamic and endocrine responses to prolonged orthostatic stress in HFpEF patients. Central venous pressure (CVP) assessed via the internal jugular vein (IJV) aspect ratio with ultrasonography, arterial pressure and heart rate were determined at supine rest and during 2 hours of moderate (25-30°) head-up tilt (HUT) in 18 stable HFpEF patients (71.2 ± 7.3 years), 14 elderly (EC), and 10 young (YC) healthy controls. Parallel endocrine measurements comprised main BV-regulating hormones: pro-atrial natriuretic peptide, copeptin, aldosterone, and erythropoietin (EPO). At supine rest, the IJV aspect ratio was higher (>30%) in HFpEF patients compared with EC and YC, while mean arterial pressure was elevated in HFpEF patients (98.0 ± 13.1 mm Hg) and EC (95.6 ± 8.3 mm Hg) versus YC (87.3 ± 5.0 mm Hg) (P < 0.05). HUT increased heart rate (+10%) and reduced the IJV aspect ratio (-52%), with similar hemodynamic effects in all groups (P for interaction ≥ 0.322). The analysis of endocrine responses to HUT revealed a group×time interaction for circulating EPO, which was increased in YC (+10%) but remained unaltered in HFpEF patients and EC. The EPO response to a given reduction in CVP is similarly impaired in HFpEF patients and elderly controls, suggesting an age-dependent dissociation of EPO production from hemodynamic regulation in the HFpEF condition.
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Affiliation(s)
- David Montero
- University Heart CenterUniversity Hospital ZurichZurichSwitzerland
- Libin Cardiovascular Institute of Alberta, Faculty of KinesiologyUniversity of CalgaryCalgaryCanada
| | - Thomas Haider
- Institute of PhysiologyUniversity of ZurichZurichSwitzerland
| | - Jens Barthelmes
- University Heart CenterUniversity Hospital ZurichZurichSwitzerland
| | - Jens P. Goetze
- Department of Clinical BiochemistryRigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | | | - Carsten Lundby
- Department of Clinical MedicineRigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Isabella Sudano
- University Heart CenterUniversity Hospital ZurichZurichSwitzerland
| | - Frank Ruschitzka
- University Heart CenterUniversity Hospital ZurichZurichSwitzerland
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163
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Abstract
BACKGROUND Pulmonary hypertension (PH) comprises a group of complex and heterogenous conditions, characterised by elevated pulmonary artery pressure, and which left untreated leads to right-heart failure and death. PH includes World Health Organisation (WHO) Group 1 pulmonary arterial hypertension (PAH); Group 2 consists of PH due to left-heart disease (PH-LHD); Group 3 comprises PH as a result of lung diseases or hypoxia, or both; Group 4 includes PH due to chronic thromboembolic occlusion of pulmonary vasculature (CTEPH), and Group 5 consists of cases of PH due to unclear and/or multifactorial mechanisms including haematological, systemic, or metabolic disorders. Phosphodiesterase type 5 (PDE5) inhibitors increase vasodilation and inhibit proliferation. OBJECTIVES To determine the efficacy of PDE5 inhibitors for pulmonary hypertension in adults and children. SEARCH METHODS We performed searches of CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science up to 26 September 2018. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials that compared any PDE5 inhibitor versus placebo, or any other PAH disease-specific therapies, for at least 12 weeks. We include separate analyses for each PH group. DATA COLLECTION AND ANALYSIS We imported studies identified by the search into a reference manager database. We retrieved the full-text versions of relevant studies, and two review authors independently extracted data. Primary outcomes were: change in WHO functional class, six-minute walk distance (6MWD), and mortality. Secondary outcomes were haemodynamic parameters, quality of life/health status, dyspnoea, clinical worsening (hospitalisation/intervention), and adverse events. When appropriate, we performed meta-analyses and subgroup analyses by severity of lung function, connective tissue disease diagnosis, and radiological pattern of fibrosis. We assessed the evidence using the GRADE approach and created 'Summary of findings' tables. MAIN RESULTS We included 36 studies with 2999 participants (with pulmonary hypertension from all causes) in the final review. Trials were conducted for 14 weeks on average, with some as long as 12 months. Two trials specifically included children.Nineteen trials included group 1 PAH participants. PAH participants treated with PDE5 inhibitors were more likely to improve their WHO functional class (odds ratio (OR) 8.59, 95% confidence interval (CI) 3.95 to 18.72; 4 trials, 282 participants), to walk 48 metres further in 6MWD (95% CI 40 to 56; 8 trials, 880 participants), and were 22% less likely to die over a mean duration of 14 weeks (95% CI 0.07 to 0.68; 8 trials, 1119 participants) compared to placebo (high-certainty evidence). The number needed to treat to prevent one additional death was 32 participants. There was an increased risk of adverse events with PDE5 inhibitors, especially headache (OR 1.97, 95% CI 1.33 to 2.92; 5 trials, 848 participants), gastrointestinal upset (OR 1.63, 95% CI 1.07 to 2.48; 5 trials, 848 participants), flushing (OR 4.12, 95% CI 1.83 to 9.26; 3 trials, 748 participants), and muscle aches and joint pains (OR 2.52, 95% CI 1.59 to 3.99; 4 trials, 792 participants).Data comparing PDE5 inhibitors to placebo whilst on other PAH-specific therapy were limited by the small number of included trials. Those PAH participants on PDE5 inhibitors plus combination therapy walked 19.66 metres further in six minutes (95% CI 9 to 30; 4 trials, 509 participants) compared to placebo (moderate-certainty evidence). There were limited trials comparing PDE5 inhibitors directly with other PAH-specific therapy (endothelin receptor antagonists (ERAs)). Those on PDE5 inhibitors walked 49 metres further than on ERAs (95% CI 4 to 95; 2 trials, 36 participants) (low-certainty evidence). There was no evidence of a difference in WHO functional class or mortality across both treatments.Five trials compared PDE5 inhibitors to placebo in PH secondary to left-heart disease (PH-LHD). The quality of data were low due to imprecision and inconsistency across trials. In those with PH-LHD there were reduced odds of an improvement in WHO functional class using PDE5 inhibitors compared to placebo (OR 0.53, 95% CI 0.32 to 0.87; 3 trials, 285 participants), and those using PDE5 inhibitors walked 34 metres further compared to placebo (95% CI 23 to 46; 3 trials, 284 participants). There was no evidence of a difference in mortality. Five trials compared PDE5 inhibitors to placebo in PH secondary to lung disease/hypoxia, mostly in COPD. Data were of low quality due to imprecision of effect and inconsistency across trials. There was a small improvement of 27 metres in 6MWD using PDE5 inhibitors compared to placebo in those with PH due to lung disease. There was no evidence of worsening hypoxia using PDE5 inhibitors, although data were limited. Three studies compared PDE5 inhibitors to placebo or other PAH-specific therapy in chronic thromboembolic disease. There was no significant difference in any outcomes. Data quality was low due to imprecision of effect and heterogeneity across trials. AUTHORS' CONCLUSIONS PDE5 inhibitors appear to have clear beneficial effects in group 1 PAH. Sildenafil, tadalafil and vardenafil are all efficacious in this clinical setting, and clinicians should consider the side-effect profile for each individual when choosing which PDE5 inhibitor to prescribe.While there appears to be some benefit for the use of PDE5 inhibitors in PH-left-heart disease, it is not clear based on the mostly small, short-term studies, which type of left-heart disease stands to benefit. These data suggest possible harm in valvular heart disease. There is no clear benefit for PDE5 inhibitors in pulmonary hypertension secondary to lung disease or chronic thromboembolic disease. Further research is required into the mechanisms of pulmonary hypertension secondary to left-heart disease, and cautious consideration of which subset of these patients may benefit from PDE5 inhibitors. Future trials in PH-LHD should be sufficiently powered, with long-term follow-up, and should include invasive haemodynamic data, WHO functional class, six-minute walk distance, and clinical worsening.
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Affiliation(s)
- Hayley Barnes
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
| | - Zoe Brown
- St Vincent's HospitalMelbourneAustralia
| | | | - Trevor Williams
- The Alfred HospitalDepartment of Respiratory MedicineCommercial RdMelbourneAustralia3004
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164
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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: 344] [Impact Index Per Article: 68.8] [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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165
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Cimato TR, Canty JM. Right Ventricular Pulmonary Coupling as a Therapeutic Target in Heart Failure With Preserved Ejection Fraction. Circ Res 2019; 124:186-188. [PMID: 30653431 DOI: 10.1161/circresaha.118.314356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas R Cimato
- From the VA WNY Health Care System and the Departments of Medicine, Pharmacology and Toxicology, Physiology and Biophysics, and Biomedical Engineering, and The Clinical and Translational Research Center of the University at Buffalo, NY
| | - John M Canty
- From the VA WNY Health Care System and the Departments of Medicine, Pharmacology and Toxicology, Physiology and Biophysics, and Biomedical Engineering, and The Clinical and Translational Research Center of the University at Buffalo, NY
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166
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Raina A, Meeran T. Right Ventricular Dysfunction and Its Contribution to Morbidity and Mortality in Left Ventricular Heart Failure. Curr Heart Fail Rep 2019; 15:94-105. [PMID: 29468529 DOI: 10.1007/s11897-018-0378-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE In patients with left-sided HF, there has been less emphasis on the pathophysiology of the RV in terms of diagnostic evaluation and treatment, versus focus on structural abnormalities of the LV. This review seeks to delineate the importance of RV dysfunction in terms of its contribution to symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. RECENT FINDINGS Recent studies have demonstrated that RV dysfunction is common in both HFpEF and HFrEF, but more pronounced in HFrEF. LV dysfunction and atrial fibrillation are most commonly associated with RV dysfunction in left-sided HF. RV dysfunction may develop due to afterload-dependent and afterload-independent pathways. Regardless, RV dysfunction is strongly associated with functional limitations and worsened survival in patients with left-sided HF. In patients with HFpEF, a recent study showed that RV failure was the most common cause of overall mortality. Among LVAD patients and patients post-cardiac transplantation, RV dysfunction is also strongly associated with survival. Despite a number of previous and ongoing clinical trials that target the RV directly or decrease RV afterload in left-sided HF, there are no definitive therapies specifically targeting RV dysfunction in left-sided HF patients CONCLUSIONS: RV dysfunction is an important determinant of symptomatic limitations and cardiovascular outcomes in patients with left-sided HF. Further research is needed to developed pharmacotherapy that may target the RV specifically in left-sided HF patients.
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Affiliation(s)
- Amresh Raina
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA. .,Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212-4772, USA.
| | - Talha Meeran
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
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167
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Patel RB, Shah SJ. Drug Targets for Heart Failure with Preserved Ejection Fraction: A Mechanistic Approach and Review of Contemporary Clinical Trials. Annu Rev Pharmacol Toxicol 2019; 59:41-63. [PMID: 30296895 PMCID: PMC6327844 DOI: 10.1146/annurev-pharmtox-010818-021136] [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] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for over half of prevalent heart failure (HF) worldwide, and prognosis after hospitalization for HFpEF remains poor. Due, at least in part, to the heterogeneous nature of HFpEF, drug development has proved immensely challenging. Currently, there are no universally accepted therapies that alter the clinical course of HFpEF. Despite these challenges, important mechanistic understandings of the disease have revealed that the pathophysiology of HFpEF is distinct from that of HF with reduced ejection fraction and have also highlighted potential new therapeutic targets for HFpEF. Of note, HFpEF is a systemic syndrome affecting multiple organ systems. Depending on the organ systems involved, certain novel therapies offer promise in reducing the morbidity of the HFpEF syndrome. In this review, we aim to discuss novel pharmacotherapies for HFpEF based on its unique pathophysiology and identify key research strategies to further elucidate mechanistic pathways to develop novel therapeutics in the future.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA;
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA;
- T1 Center for Cardiovascular Therapeutics, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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168
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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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169
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Zhang YT, Xue JJ, Wang Q, Cheng SY, Chen ZC, Li HY, Shan JJ, Cheng KL, Zeng WJ. Dehydroepiandrosterone attenuates pulmonary artery and right ventricular remodeling in a rat model of pulmonary hypertension due to left heart failure. Life Sci 2018; 219:82-89. [PMID: 30605649 DOI: 10.1016/j.lfs.2018.12.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/14/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
Abstract
AIM Pulmonary hypertension due to left heart failure (PH-LHF) is the most common cause of pulmonary hypertension. However, therapies for PH-LHF are lacking. Therefore, we investigated the effects and potential mechanism of dehydroepiandrosterone (DHEA) treatment in an experimental model of PH-LHF. MAIN METHOD PH-LHF was induced in rats via ascending aortic banding. The rats then received daily DHEA from Day 1 to Day 63 for the prevention protocol or from Day 49 to Day 63 for the reversal protocol. Other ascending aortic banding rats were left untreated to allow development of PH and right ventricular (RV) failure. Sham ascending aortic banding rats served as controls. KEY FINDING Significant increases in mean pulmonary arterial pressure (mPAP) and right ventricular end-diastolic diameter (RVEDD) were observed in the PH-LHF group. Therapy with DHEA prevented LHF-induced PH and RV failure by preserving mPAP and preventing RV hypertrophy and pulmonary artery remodeling. In preexisting severe PH, DHEA attenuated most lung and RV abnormalities. The beneficial effects of DHEA in PH-LHF seem to result from depression of the STAT3 signaling pathway in the lung. SIGNIFICANT DHEA not only prevents the development of PH-LHF and RV failure but also rescues severe preexisting PH-LHF.
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Affiliation(s)
- Yi-Tao Zhang
- Cardiovascular Department of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jiao-Jie Xue
- Cardiovascular Department of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qing Wang
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, USA
| | - Shi-Yao Cheng
- Cardiovascular Department of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zhi-Chong Chen
- Cardiovascular Department of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Hua-Yang Li
- Zhong Shan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jia-Jie Shan
- the School of Medicine, South China University of Technology, Guangzhou, Guangdong Province, China
| | - Kang-Lin Cheng
- Cardiovascular Department of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.
| | - Wei-Jie Zeng
- Cardiovascular Department of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China.
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Cao JY, Wales KM, Cordina R, Lau EM, Celermajer DS. Pulmonary vasodilator therapies are of no benefit in pulmonary hypertension due to left heart disease: A meta-analysis. Int J Cardiol 2018; 273:213-220. [DOI: 10.1016/j.ijcard.2018.09.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 07/25/2018] [Accepted: 09/10/2018] [Indexed: 12/29/2022]
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Potts Shunt Improves Right Ventricular Function and Coupling With Pulmonary Circulation in Children With Suprasystemic Pulmonary Arterial Hypertension. Circ Cardiovasc Imaging 2018; 11:e007964. [DOI: 10.1161/circimaging.118.007964] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Gori M, D'Elia E, Senni M. Sacubitril/valsartan therapeutic strategy in HFpEF: Clinical insights and perspectives. Int J Cardiol 2018; 281:158-165. [PMID: 30420146 DOI: 10.1016/j.ijcard.2018.06.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/06/2018] [Accepted: 06/13/2018] [Indexed: 01/09/2023]
Abstract
Sacubitril/valsartan represents the first of a new class of drugs able to act as a neprilysin inhibitor and as an angiotensin receptor blocker. This double inhibition has the advantage of concomitantly blocking a pro-fibrotic/pro-hypertrophic mechanism (angiotensin receptor blocker component) while stimulating an anti-fibrotic/anti-hypertrophic mechanism (neprilysin inhibitor component). Furthermore, the novel drug has natriuretic and diuretic properties, better preserves renal function, provides better blood pressure control as compared to renin angiotensin system inhibitors, and improves ventricular-arterial coupling. Consequently, sacubitril/valsartan provides greater target organ protection than angiotensin receptor blocker therapy alone, including cardiac, vascular, and renal protection. Up to now, this drug does not have an indication in patients with heart failure with preserved ejection fraction (HFpEF). However, its complex mechanism of action and previous experimental and clinical data seem to suggest its possible success in HFpEF. In this review we highlight and discuss the rationale, clinical insights, and perspectives behind the use of sacubitril/valsartan in HFpEF, specifically referring to its possible efficacy in pathophysiologic mechanisms, such as myocardial hypertrophy, fibrosis, and ischemia, renal dysfunction, impaired ventricular-arterial coupling, which are all tightly related to elevated left ventricular end diastolic pressure, a common hallmark for this multifaceted syndrome.
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Affiliation(s)
- Mauro Gori
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Emilia D'Elia
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy.
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173
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Abstract
Pulmonary hypertension (PH) is a common hemodynamic evolution of heart failure (HF) with preserved or reduced ejection fraction, responsible for congestion, symptoms worsening, exercise limitation, and negative outcome. In HF of any origin, PH develops in response to a passive backward pressure transmission as result of increased left atrial pressure. Sustained pressure injury and chronic venous congestion can trigger pulmonary vasoconstriction and vascular remodeling, leading to irreversible pulmonary vascular disease, right ventricular hypertrophy, and failure. In this article, the key determinants of this "dangerous liaison" are analyzed with some digressions on related "leitmotiv" at the horizon.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, IRCCS Policlinico San Donato, Piazza E. Malan 2, San Donato Milanese, Milano 20097, Italy.
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174
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Guay CA, Morin-Thibault LV, Bonnet S, Lacasse Y, Lambert C, Lega JC, Provencher S. Pulmonary hypertension-targeted therapies in heart failure: A systematic review and meta-analysis. PLoS One 2018; 13:e0204610. [PMID: 30307953 PMCID: PMC6181322 DOI: 10.1371/journal.pone.0204610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022] Open
Abstract
Background Pulmonary hypertension (PH) due to left heart failure (HF) is the most common form of PH. However, treatment is unclear because there are conflicting results about safety and efficacy of PH-targeted therapies. Objectives To assess the effects of PH-targeted therapy on exercise capacity in HF patients. Methods MEDLINE, EMBASE and the Cochrane Library were searched from January 1990 to July 2017 for randomized controlled trials comparing PH-targeted therapies to conventional therapy in HF. The primary outcome was to assess the effects on exercise capacity. Secondary outcomes included mortality, hospitalisation, NT-proBNP levels, echocardiographic and hemodynamics parameters and discontinuation rate. Results 22 studies were included (n = 5448), including 3, 8 and 11 studies with low, high and unknown risk of bias, respectively. PH-targeted therapies were associated with an improvement of exercise capacity (standardized mean difference 0.29;95%CI:0.08–0.50, p = 0.006). Pre-specified subgroup analyses found that this improvement was predominantly observed in studies evaluating phosphodiesterase-5 inhibitors and prostanoids and in patients with reduced ejection fraction. Moreover, systolic pulmonary artery pressure measured by echocardiography was improved (mean difference: -7.5mmHg; [95%CI]: -14.9,-0.1, p = 0.05), which was also entirely driven by studies evaluating phosphodiesterase-5 inhibitors. However, PH-targeted therapies were associated with an increased treatment discontinuation rates and a potential increase in mortality compared to standard treatment. Conclusions In conclusion, PH-targeted therapies and especially phosphodiesterase-5 inhibitors may improve exercise capacity in patients with HF. However, an increase in adverse outcomes was likely. Moreover, most studies were at high or unknown risk of bias, precluding confident conclusions about the effects of PH-targeted therapies.
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Affiliation(s)
- Charles-Antoine Guay
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Louis-Vincent Morin-Thibault
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Sebastien Bonnet
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
| | - Yves Lacasse
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
| | - Caroline Lambert
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
| | - Jean-Christophe Lega
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Médecine Interne-Pathologie Vasculaire, Lyon, France
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Laval University, Quebec City, Canada
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Laval University, Quebec City, Canada
- Department of Medicine, Université Laval, Québec, Canada
- * E-mail:
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Amsallem M, Mercier O, Kobayashi Y, Moneghetti K, Haddad F. Forgotten No More: A Focused Update on the Right Ventricle in Cardiovascular Disease. JACC-HEART FAILURE 2018; 6:891-903. [PMID: 30316939 DOI: 10.1016/j.jchf.2018.05.022] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/17/2018] [Accepted: 05/30/2018] [Indexed: 12/13/2022]
Abstract
In the last decade, there has been renewed interest in the study of the right ventricle. It is now well established that right ventricular function is a strong predictor of mortality, not only in heart failure but also in pulmonary hypertension, congenital heart disease, and cardiothoracic surgery. The right ventricle is part of a cardiopulmonary unit with connections to the pulmonary circulation, venous return, atria, and left ventricle. In this context, ventriculoarterial coupling, interventricular interactions, and pericardial constraint become important to understand right ventricular adaptation to injury or abnormal loading conditions. This state-of-the-art review summarizes major advances that occurred in the field of right ventricular research over the last decade. The first section focuses on right ventricular physiology and pulmonary circulation. The second section discusses the emerging data on right ventricular phenotyping, highlighting the importance of myocardial deformation (strain) imaging and assessment of end-systolic dimensions. The third section reviews recent clinical trials involving patients at risk for or with established right ventricular failure, focusing on beta blockade, phosphodiesterase inhibition, and mechanical support of the failing right heart. The final section presents a perspective on active areas of research that are most likely to translate in clinical practice in the next decade.
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Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California; Vera Moulton Wall Center at Stanford, Stanford, California; Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Olaf Mercier
- Research and Innovation Unit, INSERM U999, DHU Torino, Paris Sud University, Marie Lannelongue Hospital, Le Plessis Robinson, France; Department of Cardiothoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | - Kegan Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cardiovascular Institute, Stanford, California; Vera Moulton Wall Center at Stanford, Stanford, California.
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Johns CS, Wild JM, Rajaram S, Tubman E, Capener D, Elliot C, Condliffe R, Charalampopoulos A, Kiely DG, Swift AJ. Identifying At-Risk Patients with Combined Pre- and Postcapillary Pulmonary Hypertension Using Interventricular Septal Angle at Cardiac MRI. Radiology 2018; 289:61-68. [PMID: 29969067 PMCID: PMC6190488 DOI: 10.1148/radiol.2018180120] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 12/21/2022]
Abstract
Purpose To assess interventricular septal (IVS) angle in the identification of combined pre- and postcapillary pulmonary hypertension (Cpc-PH) in patients with pulmonary hypertension (PH) due to left-sided heart disease. Materials and Methods In this retrospective study, consecutive, incident patients suspected of having PH underwent same-day right-sided heart catheterization (RHC) and MRI at a PH referral center between April 2012 and April 2017. The diagnostic accuracy of the IVS angle to identify Cpc-PH in patients with pulmonary arterial wedge pressure (PAWP) greater than 15 mmHg was assessed by using receiver operator characteristic curves, sensitivity, specificity, and negative and positive predictive values. IVS angle also was assessed as a predictor of all-cause mortality by using Cox uni- and multivariable proportional hazards regression. Results A total of 708 patients underwent same-day MRI and RHC, and 171 patients had PAWP greater than 15 mmHg. Mean age was 70 years (range, 21-90 years) (women: mean age, 69 years; range, 21-88 years) (men: mean age, 71 years; range, 43-90 years). Systolic IVS angle correlated with diastolic pulmonary gradient (DPG) (r = 0.739, P < .001). Receiver operating characteristic curve analysis showed septal angle enabled identification of Cpc-PH (DPG ≥ 7), with an area under the receiver operating characteristic curve of 0.911 (P < .001). A 160° threshold, derived from the first half of patients with raised PAWP, enabled identification of a DPG of at least 7 mmHg with 67% sensitivity and 93% specificity (P < .001) in the second cohort of patients with raised PAWP. IVS angle was predictive of all-cause mortality (standardized univariable hazard ratio, 1.615; P < .01). Conclusion The systolic interventricular septal angle is elevated in patients with combined pre- and postcapillary pulmonary hypertension and enables one to predict those patients who have PH due to left-sided heart disease who have an increased risk of death. Published under a CC BY 4.0 license. Online supplemental material is available for this article.
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Affiliation(s)
- Christopher S. Johns
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - James M. Wild
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Smitha Rajaram
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Euan Tubman
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - David Capener
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Charlie Elliot
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Robin Condliffe
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Athanasios Charalampopoulos
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - David G. Kiely
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
| | - Andrew J. Swift
- From the Academic Department of Radiology, Academic Unit of
Radiology, Department of Infection, Immunity & Cardiovascular Disease,
Magnetic Resonance Imaging Unit, University of Sheffield, Royal Hallamshire
Hospital, Glossop Rd, Floor C, Sheffield S10 2JF, England (C.S.J., J.M.W., E.T.,
D.C., A.J.S.); Sheffield Pulmonary Vascular Disease Institute (C.E., R.C., A.C.,
D.G.K.) and Department of Radiology (S.R.), Sheffield Teaching Hospitals,
Sheffield, England; and Insigneo Institute for In Silico Medicine, University of
Sheffield, Sheffield, England (A.J.S.)
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177
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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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178
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Parikh KS, Sharma K, Fiuzat M, Surks HK, George JT, Honarpour N, Depre C, Desvigne-Nickens P, Nkulikiyinka R, Lewis GD, Gomberg-Maitland M, O’Connor CM, Stockbridge N, Califf RM, Konstam MA, Januzzi JL, Solomon SD, Borlaug BA, Shah SJ, Redfield MM, Felker GM. Heart Failure With Preserved Ejection Fraction Expert Panel Report. JACC-HEART FAILURE 2018; 6:619-632. [DOI: 10.1016/j.jchf.2018.06.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/20/2018] [Accepted: 06/20/2018] [Indexed: 01/08/2023]
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179
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Sysol JR, Machado RF. Classification and pathophysiology of pulmonary hypertension. ACTA ACUST UNITED AC 2018. [DOI: 10.1002/cce2.71] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- J. R. Sysol
- Department of Medicine; Division of Pulmonary, Critical Care, Sleep and Allergy; University of Illinois at Chicago; Chicago, 60612 Illinois
- Department of Pharmacology; University of Illinois at Chicago; Chicago, 60612 Illinois
| | - R. F. Machado
- Department of Medicine; Division of Pulmonary, Critical Care, Sleep and Allergy; University of Illinois at Chicago; Chicago, 60612 Illinois
- Department of Pharmacology; University of Illinois at Chicago; Chicago, 60612 Illinois
- Division of Pulmonary; Critical Care; Sleep, and Occupational Medicine; Indiana University Department of Medicine; Indianapolis, 46202 Indiana
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180
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Elinoff JM, Agarwal R, Barnett CF, Benza RL, Cuttica MJ, Gharib AM, Gray MP, Hassoun PM, Hemnes AR, Humbert M, Kolb TM, Lahm T, Leopold JA, Mathai SC, McLaughlin VV, Preston IR, Rosenzweig EB, Shlobin OA, Steen VD, Zamanian RT, Solomon MA. Challenges in Pulmonary Hypertension: Controversies in Treating the Tip of the Iceberg. A Joint National Institutes of Health Clinical Center and Pulmonary Hypertension Association Symposium Report. Am J Respir Crit Care Med 2018; 198:166-174. [PMID: 29425462 PMCID: PMC6058980 DOI: 10.1164/rccm.201710-2093pp] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Richa Agarwal
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Raymond L. Benza
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael J. Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ahmed M. Gharib
- National Institute of Diabetes, Digestive, and Kidney Diseases, and
| | | | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre (Assistance Publique–Hôpitaux de Paris), Institut National de la Santé et de la Recherche Médicale U999, University Paris–Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Lahm
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jane A. Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Vallerie V. McLaughlin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ioana R. Preston
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Oksana A. Shlobin
- Pulmonary Vascular Disease Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Virginia D. Steen
- Rheumatology Division, Department of Medicine, Georgetown University, Washington, DC; and
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181
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Lam CSP, Voors AA, de Boer RA, Solomon SD, van Veldhuisen DJ. Heart failure with preserved ejection fraction: from mechanisms to therapies. Eur Heart J 2018; 39:2780-2792. [DOI: 10.1093/eurheartj/ehy301] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 05/08/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Carolyn S P Lam
- National Heart Centre Singapore, 5 Hospital Drive, Singapore
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, Hanzeplein 1, Groningen, the Netherlands
- Duke-National University of Singapore Medical School, Singapore
- Cardiovascular Research Institute, National University Heart Centre, Singapore
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, Hanzeplein 1, Groningen, the Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, Hanzeplein 1, Groningen, the Netherlands
| | - Scott D Solomon
- Harvard Medical School, Harvard University, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, AB31, Hanzeplein 1, Groningen, the Netherlands
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182
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Guazzi M. Partitioning of pulmonary vascular resistances in group 2 pulmonary hypertension: insightful suggestions for bridging haemodynamics to underlying mechanisms. Eur Respir J 2018; 51:51/5/1800816. [PMID: 29794124 DOI: 10.1183/13993003.00816-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Marco Guazzi
- Dept of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy .,Dept of Cardiology University, IRCCS Policlinico San Donato, Milan, Italy
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183
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Bhogal S, Mukherjee D, Banerjee S, Islam AM, Daggubati R, Paul TK. Current Trends and Future Perspectives in the Treatment of Pulmonary Hypertension: WHO Group II-V. Curr Probl Cardiol 2018; 43:217-231. [PMID: 29153390 DOI: 10.1016/j.cpcardiol.2017.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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184
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Impaired Alveolar Capillary Membrane Diffusion: A Recently Recognized Contributor to Exertional Dyspnea in Heart Failure With Preserved Ejection Fraction. JACC-HEART FAILURE 2018; 4:499-501. [PMID: 27256753 DOI: 10.1016/j.jchf.2016.03.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 11/21/2022]
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185
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Gerges C, Gerges M, Fesler P, Pistritto AM, Konowitz NP, Jakowitsch J, Celermajer DS, Lang I. In-depth haemodynamic phenotyping of pulmonary hypertension due to left heart disease. Eur Respir J 2018; 51:13993003.00067-2018. [DOI: 10.1183/13993003.00067-2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/10/2018] [Indexed: 12/22/2022]
Abstract
The commonest cause of pulmonary hypertension (PH) is left heart disease (LHD). The current classification system for definitions of PH-LHD is under review. We therefore performed prospective in-depth invasive haemodynamic phenotyping in order to assess the site of increased pulmonary vascular resistance (PVR) in PH-LHD subsets.Based on pulmonary artery occlusion waveforms yielding an estimate of the effective capillary pressure, we partitioned PVR in larger arterial (Rup, upstream resistance) and small arterial plus venous components (Rds, downstream resistance). In the case of small vessel disease, Rup decreases and Rds increases. Inhaled nitric oxide (NO) testing was used to assess acute vasoreactivity.Right ventricular afterload (PVR, pulmonary arterial compliance and effective arterial elastance) was significantly higher in combined post- and pre-capillary PH (Cpc-PH, n=35) than in isolated post-capillary PH (Ipc-PH, n=20). Right ventricular afterload decreased during inhalation of NO in Cpc-PH and idiopathic pulmonary arterial hypertension (n=31), but remained unchanged in Ipc-PH. Rup was similar in Cpc-PH (66.8±10.8%) and idiopathic pulmonary arterial hypertension (65.0±12.2%; p=0.530) suggesting small vessel disease, but significantly higher in Ipc-PH (96.5±4.5%; p<0.001) suggesting upstream transmission of elevated left atrial pressure.Right ventricular afterload is driven by elevated left atrial pressure in Ipc-PH and is further increased by elevated small vessel resistance in Cpc-PH. Cpc-PH is responsive to inhaled NO. Our data support current definitions of PH-LHD subsets.
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186
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Effects of Fasudil on Patients with Pulmonary Hypertension Associated with Left Ventricular Heart Failure with Preserved Ejection Fraction: A Prospective Intervention Study. Can Respir J 2018; 2018:3148259. [PMID: 29785232 PMCID: PMC5892244 DOI: 10.1155/2018/3148259] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 09/19/2017] [Indexed: 12/28/2022] Open
Abstract
Background Pulmonary hypertension due to left ventricular heart failure with preserved ejection fraction (PH-HFpEF) is an increasingly medical problem. The aim of the study was to evaluate the clinical efficacy of fasudil on PH-HFpEF elderly patients and to figure out the subtype of PH-HFpEF which may be the therapeutic object of fasudil. Method 58 PH-HFpEF elderly patients were enrolled. Patients were diagnosed with passive pulmonary hypertension (PPH) or reactive pulmonary hypertension (RPH) by right heart catheterization and all receiving Rho kinase inhibitor fasudil for 2 weeks. The endpoint includes changes in SpO2, NT-pro BNP, cardiac functional classification, and echocardiography measurements after 2 weeks treatment. Results The course of disease in the RPH group was longer than the PPH group (p < 0.05). Cardiac output was found to be worse in the RPH group than the PPH group (p < 0.01). Besides, the RPH group demonstrated a greater transpulmonary pressure gradient (TPG) and pulmonary vascular resistance (PVR) than the PPH group (p < 0.01 for both) as well as pulmonary arterial systolic pressure (PASP) and mean pulmonary arterial pressure (mPAP) (p < 0.01 for both), which fits the feature of RPH. After treatment of fasudil, in RPH group, PASP significantly decreased (p < 0.01) with decreased E/E′ and increased E/A (p < 0.05 for both), indicating that pulmonary haemodynamics and cardiac diastolic function were ameliorated, but the measurements in the PPH group had no significant changes. NT-pro BNP and 6 MWD of both groups were improved (p < 0.05). The total effective rate of the RPH group was 74.29%, which was higher than 47.83% of the PPH group (p < 0.05). Conclusion The Rho kinase inhibitor fasudil can improve pulmonary and left ventricular haemodynamics in patients with PH-HFpEF. The total effective rate was higher in the RPH group. Fasudil may be a promising targeted drug for the RPH in PH-HFpEF patients. This trial is registered with ChiCTR-INR-16009511.
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187
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Krittanawong C, Kukin ML. Current Management and Future Directions of Heart Failure With Preserved Ejection Fraction: a Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:28. [PMID: 29557071 DOI: 10.1007/s11936-018-0623-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF), a complex and debilitating syndrome, is commonly seen in elderly populations. Exacerbation of HFpEF is among the most common reasons for hospital admission in the USA. The high rate of morbidity and mortality from this condition underscores the fact that HFpEF is heterogeneous, complex, and poorly characterized. Randomized, controlled trials have been very successful at identifying treatments for HF with reduced ejection fraction (HFrEF), but effective treatment options for HFpEF are lacking. Here, we discuss (1) the pathophysiology of HFpEF, (2) a standardized diagnostic and therapeutic approach, (3) a comparison of the management of recent guidelines, and (4) challenges and future directions for HFpEF management. The authors believe that it is important to identify new subtypes of HFpEF to better classify genotypes and phenotypes of HFpEF and to develop novel targeted therapies. It is our hypothesis that big data analytics will shine new light on unique HFpEF phenotypes that better respond to treatment modalities.
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Affiliation(s)
- Chayakrit Krittanawong
- Division of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, 1000 10th Ave, New York, NY, 10019, USA.
| | - Marrick L Kukin
- Division of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, 1000 10th Ave, New York, NY, 10019, USA
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188
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Abstract
Novel cardioprotective agents are needed in both heart failure (HF) and myocardial infarction. Increasing evidence from cellular studies and animal models indicate protective effects of phosphodiesterase-5 (PDE5) inhibitors, drugs usually reserved as treatments of erectile dysfunction and pulmonary arterial hypertension. PDE5 inhibitors have been shown to improve contractile function in systolic HF, regress left ventricular hypertrophy, reduce myocardial infarct size and suppress ischaemia-induced ventricular arrhythmias. Underpinning these actions are complex but increasingly understood cellular mechanisms involving the cyclic GMP activation of protein kinase-G in both cardiac myocytes and the vasculature. In clinical trials, PDE5 inhibitors improve symptoms and ventricular function in systolic HF, and accumulating epidemiological data indicate a reduction in cardiovascular events and mortality in PDE5 inhibitor users at high cardiovascular risk. Here, we focus on the translation of underpinning basic science to clinical studies and report that PDE5 inhibitors act through a number of cardioprotective mechanisms, including a direct myocardial action independent of the vasculature. We conclude that future clinical trials should be designed with these mechanisms in mind to identify patient subsets that derive greatest treatment benefit from these novel cardioprotective agents.
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Affiliation(s)
- David Charles Hutchings
- Unit of Cardiac Physiology, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon George Anderson
- Unit of Cardiac Physiology, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jessica L Caldwell
- Unit of Cardiac Physiology, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrew W Trafford
- Unit of Cardiac Physiology, Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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189
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Currie BJ, Johns C, Chin M, Charalampopolous T, Elliot CA, Garg P, Rajaram S, Hill C, Wild JW, Condliffe RA, Kiely DG, Swift AJ. CT derived left atrial size identifies left heart disease in suspected pulmonary hypertension: Derivation and validation of predictive thresholds. Int J Cardiol 2018. [PMID: 29530618 PMCID: PMC5899969 DOI: 10.1016/j.ijcard.2018.02.114] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Patients with pulmonary hypertension due to left heart disease (PH-LHD) have overlapping clinical features with pulmonary arterial hypertension making diagnosis reliant on right heart catheterization (RHC). This study aimed to investigate computed tomography pulmonary angiography (CTPA) derived cardiopulmonary structural metrics, in comparison to magnetic resonance imaging (MRI) for the diagnosis of left heart disease in patients with suspected pulmonary hypertension. Methods Patients with suspected pulmonary hypertension who underwent CTPA, MRI and RHC were identified. Measurements of the cardiac chambers and vessels were recorded from CTPA and MRI. The diagnostic thresholds of individual measurements to detect elevated pulmonary arterial wedge pressure (PAWP) were identified in a derivation cohort (n = 235). Individual CT and MRI derived metrics were tested in validation cohort (n = 211). Results 446 patients, of which 88 had left heart disease. Left atrial area was a strong predictor of elevated PAWP>15 mm Hg and PAWP>18 mm Hg, area under curve (AUC) 0.854, and AUC 0.873 respectively. Similar accuracy was also identified for MRI derived LA volume, AUC 0.852 and AUC 0.878 for PAWP > 15 and 18 mm Hg, respectively. Left atrial area of 26.8 cm2 and 30.0 cm2 were optimal specific thresholds for identification of PAWP > 15 and 18 mm Hg, had sensitivity of 60%/53% and specificity 89%/94%, respectively in a validation cohort. Conclusions CTPA and MRI derived left atrial size identifies left heart disease in suspected pulmonary hypertension with high specificity. The proposed diagnostic thresholds for elevated left atrial area on routine CTPA may be a useful to indicate the diagnosis of left heart disease in suspected pulmonary hypertension. Routine CTPA can diagnose left heart disease in suspected pulmonary hypertension. Complex multiparameter models do not improve LHD diagnosis. Highly specific thresholds have been derived and validated.
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Affiliation(s)
- Benjamin J Currie
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Chris Johns
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Matthew Chin
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Pankaj Garg
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Smitha Rajaram
- Radiology Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Catherine Hill
- Radiology Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Jim W Wild
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; INSIGNEO, Institute for in silico medicine, University of Sheffield, UK
| | - Robin A Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; INSIGNEO, Institute for in silico medicine, University of Sheffield, UK
| | - Andy J Swift
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; INSIGNEO, Institute for in silico medicine, University of Sheffield, UK.
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190
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Huang W, Oliveira RK, Lei H, Systrom DM, Waxman AB. Pulmonary Vascular Resistance During Exercise Predicts Long-Term Outcomes in Heart Failure With Preserved Ejection Fraction. J Card Fail 2018; 24:169-176. [DOI: 10.1016/j.cardfail.2017.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 12/30/2022]
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191
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Singh P, Vijayakumar S, Kalogeroupoulos A, Butler J. Multiple Avenues of Modulating the Nitric Oxide Pathway in Heart Failure Clinical Trials. Curr Heart Fail Rep 2018; 15:44-52. [DOI: 10.1007/s11897-018-0383-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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192
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Ramu B, Houston BA, Tedford RJ. Pulmonary Vascular Disease: Hemodynamic Assessment and Treatment Selection—Focus on Group II Pulmonary Hypertension. Curr Heart Fail Rep 2018; 15:81-93. [DOI: 10.1007/s11897-018-0377-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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193
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Hensley MK, Levine A, Gladwin MT, Lai YC. Emerging therapeutics in pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2018; 314:L769-L781. [PMID: 29388467 DOI: 10.1152/ajplung.00259.2017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Pulmonary hypertension (PH) is a progressive and often fatal illness presenting with nonspecific symptoms of dyspnea, lower extremity edema, and exercise intolerance. Pathologically, endothelial dysfunction leads to abnormal intimal and smooth muscle proliferation along with reduced apoptosis, resulting in increased pulmonary vascular resistance and elevated pulmonary pressures. PH is subdivided into five World Health Organization groups based on the disease pathology and specific cause. While there are Food and Drug Administration-approved medications for the treatment of pulmonary arterial hypertension (PAH; Group 1 PH), as well as for chronic thromboembolic PH (Group 4 PH), the morbidity and mortality remain high. Moreover, there are no approved therapies for other forms of PH (Groups 2, 3, and 5) at present. New research has identified molecular targets that mediate vasodilation, anti-inflammatory, and antifibrotic changes within the pulmonary vasculature. Given that PAH is the most commonly studied form of PH worldwide and because recent studies have led to better mechanistic understanding of this devastating disease, in this review we attempt to provide an updated overview of new therapeutic approaches under investigation for the treatment of PH, with a particular focus on PAH, as well as to offer guidelines for future investigations.
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Affiliation(s)
- Matthew K Hensley
- Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor, Michigan
| | - Andrea Levine
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh , Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine , 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, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Yen-Chun Lai
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh , Pittsburgh, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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Abstract
Nitric oxide (NO) signalling has pleiotropic roles in biology and a crucial function in cardiovascular homeostasis. Tremendous knowledge has been accumulated on the mechanisms of the nitric oxide synthase (NOS)-NO pathway, but how this highly reactive, free radical gas signals to specific targets for precise regulation of cardiovascular function remains the focus of much intense research. In this Review, we summarize the updated paradigms on NOS regulation, NO interaction with reactive oxidant species in specific subcellular compartments, and downstream effects of NO in target cardiovascular tissues, while emphasizing the latest developments of molecular tools and biomarkers to modulate and monitor NO production and bioavailability.
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Affiliation(s)
- Charlotte Farah
- Pole of Pharmacology and Therapeutics (FATH), Institut de Recherche Experimentale et Clinique (IREC) and Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, UCL-FATH Tour Vésale 5th Floor, 52 Avenue Mounier B1.53.09, 1200 Brussels, Belgium
| | - Lauriane Y M Michel
- Pole of Pharmacology and Therapeutics (FATH), Institut de Recherche Experimentale et Clinique (IREC) and Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, UCL-FATH Tour Vésale 5th Floor, 52 Avenue Mounier B1.53.09, 1200 Brussels, Belgium
| | - Jean-Luc Balligand
- Pole of Pharmacology and Therapeutics (FATH), Institut de Recherche Experimentale et Clinique (IREC) and Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, UCL-FATH Tour Vésale 5th Floor, 52 Avenue Mounier B1.53.09, 1200 Brussels, Belgium
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195
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Echocardiographic validation of pulmonary hypertension due to heart failure with reduced ejection fraction in mice. Sci Rep 2018; 8:1363. [PMID: 29358732 PMCID: PMC5778040 DOI: 10.1038/s41598-018-19625-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/05/2018] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart diseases is the most prevalent cause of PH. The scarcity of studies exploring the pathophysiology and therapies of group II PH resides in the lack of validated small animal models with non-invasive determination of the presence and severity of PH. Heart failure (HF) was induced in mice by coronary artery ligation. Mice developed PH as evidenced by an elevated right ventricular (RV) systolic pressure and RV hypertrophy. Detailed non-invasive echocardiographic analysis on the left and right ventricles showed impaired left ventricular (LV) systolic and diastolic function. In addition, RV hypertrophy was confirmed by echo and accompanied by impaired function as well as increased pulmonary resistance. Correlation analysis validated the use of the LV wall-motion score index (WMSI) at a threshold value of ≥2.0 as a powerful and reliable indicator for the presence of PH and RV dysfunction. Echocardiography is an accurate non-invasive technique to diagnose PH in a HF mouse model. Moreover, an echocardiographic parameter of infarct size and LV function, the LV WMSI, reliably correlates with the presence of PH, RV hypertrophy and RV dysfunction and could be used to improve efficiency and design of pre-clinical studies.
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196
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Treatment of Heart Failure with Preserved Ejection Fraction. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:67-87. [PMID: 29498023 DOI: 10.1007/5584_2018_149] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a growing epidemiologic problem affecting more than half of the patients with heart failure (HF). HFpEF has a significant morbidity and mortality and so far no treatment has been clearly demonstrated to improve the outcomes in HFpEF, in contrast to the efficacy of treatment in heart failure with reduced ejection fraction (HFrEF).The failure of proven beneficial drugs in HFrEF to influence the outcome of patients with HFpEF could be related to the heterogeneity of the disease, its various phenotypes and multifactorial pathophysiology, incompletely elucidated yet. The diagnosis of HFpEF could be demanding or even inaccurate. Moreover, the therapeutic strategies were influenced by different cut-offs used to define preserved ejection fraction (EF). From this perspective, the current guidelines have classified HFpEF by an EF ≥ 50%, together with a distinct entity, heart failure with mid-range ejection fraction (HFmrEF), defined by an EF ranging from 41-49%.New therapies have been developed to interfere with the mediator pathways of HFpEF at the cellular and molecular level, including mineralocorticoid receptor antagonists, soluble guanylate cyclase stimulators, or angiotensin receptor-neprilysin inhibitors. A number of antidiabetic drugs, such as sodium/glucose cotransporter 2 inhibitors and dipeptidyl peptidase-4 inhibitors are promising options, being under research in large clinical trials. Until the results of ongoing trials shed light on these therapies, guidelines recommend empirical treatment for established HFpEF, and emphasize the crucial role of addressing cardiovascular comorbidities leading to HFpEF, in particular arterial hypertension.
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197
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Sala V, Margaria JP, Murabito A, Morello F, Ghigo A, Hirsch E. Therapeutic Targeting of PDEs and PI3K in Heart Failure with Preserved Ejection Fraction (HFpEF). Curr Heart Fail Rep 2017; 14:187-196. [PMID: 28451983 DOI: 10.1007/s11897-017-0331-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Heart Failure with preserved Ejection Fraction (HFpEF) is a prevalent disease with considerable individual and societal burden. HFpEF patients often suffer from multiple pathological conditions thatcomplicate management and adversely affect outcome, including pulmonary hypertension and chronic obstructive pulmonary disease (COPD). To date, no treatment proved to be fully effective in reducing morbidity and mortality in HFpEF, possibly due to an incomplete understanding of the underlying molecular mechanisms. RECENT FINDINGS The emerging view proposes chronic systemic inflammation, leading to endothelial dysfunction and interstitial fibrosis, as a prominent cause of HFpEF, rather than a mere co-existent disease. In the last decade, efforts from pharmaceutical companies attempted to target pharmacologically enzymes which play key roles in systemic and lung inflammation, such as the cyclic nucleotide-degrading enzymes phosphodiesterases (PDEs) and phosphoinositide-3 phosphate kinases (PI3Ks), especially to limit COPD. In this review, we will summarize major successes and drawbacks of hitting these enzymes to tackle inflammation in HFpEF-associated co-morbidities, with a major focus on the results of completed and ongoing clinical trials. Finally, we will discuss the potential of repurposing and/or developing new PDE and PI3K inhibitors for HFpEF therapy.
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Affiliation(s)
- Valentina Sala
- Department of Molecular Biotechnology, Molecular Biotechnology Center, University of Torino, Torino, Italy
- S.C. Medicina d'Urgenza, A.O.U. Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Jean Piero Margaria
- Department of Molecular Biotechnology, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Alessandra Murabito
- Department of Molecular Biotechnology, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Fulvio Morello
- S.C. Medicina d'Urgenza, A.O.U. Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Alessandra Ghigo
- Department of Molecular Biotechnology, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Emilio Hirsch
- Department of Molecular Biotechnology, Molecular Biotechnology Center, University of Torino, Torino, Italy.
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198
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Fayyaz AU, Edwards WD, Maleszewski JJ, Konik EA, DuBrock HM, Borlaug BA, Frantz RP, Jenkins SM, Redfield MM. Global Pulmonary Vascular Remodeling in Pulmonary Hypertension Associated With Heart Failure and Preserved or Reduced Ejection Fraction. Circulation 2017; 137:1796-1810. [PMID: 29246894 DOI: 10.1161/circulationaha.117.031608] [Citation(s) in RCA: 206] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 11/29/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND We hypothesized that pulmonary venous hypertension in heart failure (HF) leads to predominate remodeling of pulmonary veins and that the severity of venous remodeling is associated with the severity of pulmonary hypertension (PH) in HF. METHODS Patients with HF (n=108; 53 preserved and 55 reduced ejection fraction) with PH (HF-PH; pulmonary artery systolic pressure [PASP] ≥40 mm Hg) were compared to normal controls (n=12) and patients with primary pulmonary veno-occlusive disease (PVOD; n=17). In lung specimens from autopsy (control, HF-PH, and 7 PVOD) or surgery (10 PVOD), quantitative histomorphometry was performed in all analyzable arteries (n=4949), veins (n=7630), and small indeterminate vessels (IV; n=2168) to define percent medial thickness (arteries) and percent intimal thickness (%IT) (arteries, veins, and IV) relative to external diameter. RESULTS The average arterial percent medial thickness (control, 6.9; HF-PH, 11.0; PVOD, 15.0), arterial %IT (control, 4.9; HF-PH, 14.9; PVOD, 31.1), venous %IT (control, 14.0; HF-PH, 24.9; PVOD, 43.9), and IV %IT (control, 10.6; HF-PH, 25.8; PVOD, 50.0) in HF-PH were higher than controls (P<0.0001 for all) but lower than PVOD (P≤0.005 for all). PASP (mm Hg) was lower in HF-PH (median, 59 [interquartile range, 50-70]) than in PVOD (median, 91 [interquartile range, 82-103]). PASP correlated with arterial percent medial thickness (r=0.41) and arterial %IT (r=0.35) but more strongly with venous %IT (r=0.49) and IV %IT (r=0.55) (P<0.0001 for all). Associations between PASP and venous or IV %IT remained significant after adjusting for arterial percent medial thickness and %IT and did not vary by HF type. In patients with right heart catheterization (30 HF-PH, 14 PVOD), similar associations between the transpulmonary gradient and pulmonary vascular remodeling existed, with numerically stronger associations for venous and IV %IT. Although the PASP was slightly higher in patients with HF-PH with right ventricular dysfunction, pulmonary vascular remodeling was not more severe. Pulmonary vascular remodeling severity was associated with reductions in the diffusing capacity of the lungs. CONCLUSIONS In HF, PH is associated with global pulmonary vascular remodeling, but the severity of PH correlates most strongly with venous and small IV intimal thickening, similar to the pattern observed in PVOD. These findings expand our understanding of the pathobiology of PH in HF.
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Affiliation(s)
- Ahmed U Fayyaz
- Department of Cardiovascular Medicine (A.U.F., J.J.M., E.A.K., B.A.B., R.P.F., M.M.F.).,Department of Laboratory Medicine and Pathology (A.U.F., W.D.E., J.J.M.)
| | - William D Edwards
- Department of Laboratory Medicine and Pathology (A.U.F., W.D.E., J.J.M.)
| | - Joseph J Maleszewski
- Department of Cardiovascular Medicine (A.U.F., J.J.M., E.A.K., B.A.B., R.P.F., M.M.F.).,Department of Laboratory Medicine and Pathology (A.U.F., W.D.E., J.J.M.)
| | - Ewa A Konik
- Department of Cardiovascular Medicine (A.U.F., J.J.M., E.A.K., B.A.B., R.P.F., M.M.F.)
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine (A.U.F., J.J.M., E.A.K., B.A.B., R.P.F., M.M.F.)
| | - Robert P Frantz
- Department of Cardiovascular Medicine (A.U.F., J.J.M., E.A.K., B.A.B., R.P.F., M.M.F.)
| | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics (S.M.J.), Mayo Clinic, Rochester, MN
| | - Margaret M Redfield
- Department of Cardiovascular Medicine (A.U.F., J.J.M., E.A.K., B.A.B., R.P.F., M.M.F.)
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199
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Desai A, Desouza SA. Treatment of pulmonary hypertension with left heart disease: a concise review. Vasc Health Risk Manag 2017; 13:415-420. [PMID: 29158679 PMCID: PMC5683770 DOI: 10.2147/vhrm.s111597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure ≥ 25 mmHg, as determined by right heart catheterization. Pulmonary arterial hypertension (PAH) can no longer be considered an orphan disease given the increase in awareness and availability of new drugs. PH carries with it a dismal prognosis and leads to significant morbidity and mortality. Symptoms can range from dyspnea, fatigue and chest pain to right ventricular failure and death. PH is divided into five groups by the World Health Organization (WHO), based on etiology. The most common cause of PH in developed countries is left heart disease (group 2), owing to the epidemic of heart failure (HF). The data regarding prevalence, diagnosis and treatment of patients with group 2 PH is unclear as large, prospective, randomized controlled trials and standardized protocols do not exist. Current guidelines do not support the use of PAH-specific therapy in patients with group 2 PH. Prostacyclins, endothelin receptor antagonists, phosphodiesterase-5 inhibitors and guanylate cyclase stimulators have been tried in treatment of patients with HF and/or group 2 PH with mixed results. This review summarizes and critically appraises the evidence for diagnosis and treatment of patients with group 2 PH/HF and suggests directions for future research.
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Affiliation(s)
- Anish Desai
- Division of Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, NY, USA
| | - Shilpa A Desouza
- Division of Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, NY, USA
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200
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Weitsman T, Weisz G, Farkash R, Klutstein M, Butnaru A, Rosenmann D, Hasin T. Pulmonary Hypertension with Left Heart Disease: Prevalence, Temporal Shifts in Etiologies and Outcome. Am J Med 2017; 130:1272-1279. [PMID: 28552430 DOI: 10.1016/j.amjmed.2017.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Pulmonary hypertension has many causes. While it is conventionally thought that the most prevalent is left heart disease, little information about its proportion, causes, and implications on outcome is available. METHODS Between 1993 and 2015, 12,115 of 66,949 (18%) first adult transthoracic echocardiograms were found to have tricuspid incompetence gradient ≥40 mm Hg, a pulmonary hypertension surrogate. Left heart disease was identified in 8306 (69%) and included valve malfunction in 4115 (49%), left ventricular systolic dysfunction in 2557 (31%), and diastolic dysfunction in 1776 (21%). Patients with left heart disease, as compared with those without left heart disease, were of similar age, fewer were females (50% vs 63% P <.0001), and they had higher tricuspid incompetence gradient (median 48 mm Hg [interquartile range 43, 55] vs 46 mm Hg [42, 54] P <.0001). In reviewing trends over 20 years, the relative proportions of systolic dysfunction decreased and diastolic dysfunction increased (P for trend <.001), while valve malfunction remained the most prevalent cause of pulmonary hypertension with left heart disease. Independent predictors of mortality were age (hazard ratio [HR] 1.05; 95% CI, 1.04-1.05; P <.0001), tricuspid incompetence gradient (HR 1.02; 95% CI, 1.01-1.02, P <.0001 per mm Hg increase), and female sex (HR 0.87; 95% CI, 0.83-0.91, P <.0001). RESULTS Overall, left heart disease was not an independent risk factor for mortality (HR 1.04; 95% CI, 0.99-1.09; P = .110), but patients with left ventricular systolic dysfunction and with combined systolic dysfunction and valve malfunction had increased mortality compared with patients with pulmonary hypertension but without left heart disease (HR 1.30; 95% CI, 1.20-1.42 and HR 1.44; 95% CI, 1.33-1.55, respectively; P <.0001 for both). CONCLUSIONS Pulmonary hypertension was found to be associated with left heart disease in 69% of patients. Among these patients, valve malfunction and diastolic dysfunction emerged as prominent causes. Left ventricular dysfunction carries additional risk to patients with pulmonary hypertension.
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Affiliation(s)
- Tatyana Weitsman
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Giora Weisz
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Rivka Farkash
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Marc Klutstein
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Adi Butnaru
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - David Rosenmann
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Tal Hasin
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel.
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