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The potential for inhaled treprostinil in the treatment of pulmonary arterial hypertension. Ther Adv Respir Dis 2011; 5:195-206. [DOI: 10.1177/1753465810397693] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Inhaled treprostinil is a safe and well-tolerated approved pharmaceutical for the treatment of pulmonary arterial hypertension. In a series of open-label studies and in the pivotal trial with 253 patients, this long-acting prostacyclin analogue demonstrated pronounced pulmonary selectivity of vasodilatory effects, improved physical capacity and excellent tolerability and safety following aerosol administration. For efficient treatment, only four daily inhalations of treprostinil are necessary compared with six to nine in iloprost aerosol therapy. This review describes in detail the development of inhaled treprostinil, starting with intravenous epoprostenol followed by inhaled iloprost and subcutaneous treprostinil, all three representing well-established and widely approved prostanoid therapies for pulmonary hypertension. In order to circumvent the drawbacks of intravenous epoprostenol, stable prostacyclin analogues with similar pharmacological properties have been investigated. In addition, alternative routes of administration have been proposed and evaluated, mainly inhaled and subcutaneous delivery. The concept of inhaled treprostinil was to combine the pulmonary selectivity of an aerosolized vasodilator with the long-acting effects of a stable prostacyclin analogue. Pulmonary arterial hypertension remains, however, a severe, life-threatening disease, in spite of the enormous progress in specific drug therapy over the last decade. Therefore, further improvement of drug therapy will be essential, with clear potential for inhaled treprostinil: a reduction of inhalation frequency and duration would markedly improve quality of life and compliance, and a longer-lasting local prostanoid effect might further enhance the efficacy of inhaled treprostinil. The advantageous pharmacological properties of treprostinil offer the opportunity to establish a convenient metered dose inhaler as a delivery system, to combine inhaled treprostinil with available or future drugs for pulmonary arterial hypertension, or to develop sustained release formulations of treprostinil suitable for inhalation based on liposomes or biodegradable nanoparticles.
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202
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Utsunomiya H, Nakatani S, Okada T, Kanzaki H, Kyotani S, Nakanishi N, Kihara Y, Kitakaze M. A simple method to predict impaired right ventricular performance and disease severity in chronic pulmonary hypertension using strain rate imaging. Int J Cardiol 2011; 147:88-94. [DOI: 10.1016/j.ijcard.2009.08.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 07/14/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
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203
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Arkles JS, Opotowsky AR, Ojeda J, Rogers F, Liu T, Prassana V, Marzec L, Palevsky HI, Ferrari VA, Forfia PR. Shape of the Right Ventricular Doppler Envelope Predicts Hemodynamics and Right Heart Function in Pulmonary Hypertension. Am J Respir Crit Care Med 2011; 183:268-76. [DOI: 10.1164/rccm.201004-0601oc] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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204
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Mathier MA. The Nuts and Bolts of Interpreting Hemodynamics in Pulmonary Hypertension Associated With Diastolic Heart Failure. ACTA ACUST UNITED AC 2011. [DOI: 10.21693/1933-088x-10.1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
With the widespread application of transthoracic echocardiography as a screening tool for pulmonary hypertension (PH), we have come to appreciate the prevalence of PH associated with diastolic heart failure. Diastolic heart failure (DHF, sometimes called heart failure with preserved, or normal, left ventricular ejection fraction [HFpEF]) is quite common, and PH appears to be a fairly frequent component of DHF.1–3 The epidemiology of these conditions is described in the article by Dr Soto in this issue of Advances. There is a complex relationship between DHF and PH: the 2 may exist independent of each other or in combination; and when they exist in combination, the PH may be in proportion or out of proportion to the DHF. Cardiac catheterization is critical in differentiating among these patterns, and this distinction may lead to important modifications in treatment strategy. This requires, however, a full understanding of the proper performance and interpretation of cardiac catheterization, as well as the potential pitfalls that can limit the utility of the procedure. This article will discuss these aspects of cardiac catheterization as they pertain to patients with pulmonary arterial hypertension (PAH) and PH associated with DHF. A number of important aspects of cardiac catheterization are not covered here due to space limitations but can be obtained in a more detailed text.4
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Affiliation(s)
- Michael A. Mathier
- Director, Pulmonary Hypertension Program, University of Pittsburgh, Medical Center, Pittsburgh, Pennsylvania
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205
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Mielniczuk LM, Birnie D, Ziadi MC, deKemp RA, DaSilva JN, Burwash I, Tang AT, Davies RA, Haddad H, Guo A, Aung M, Williams K, Ukkonen H, Beanlands RS. Relation Between Right Ventricular Function and Increased Right Ventricular [
18
F]Fluorodeoxyglucose Accumulation in Patients With Heart Failure. Circ Cardiovasc Imaging 2011; 4:59-66. [DOI: 10.1161/circimaging.109.905984] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Left heart failure is characterized by alterations in metabolic substrate utilization, and metabolic modulation may be a future strategy in the management of heart failure. Little is known about cardiac metabolism in the right ventricle and how it relates to other measures of right ventricular (RV) function. This study was designed to measure glucose metabolism in the right ventricle, as estimated by [
18
F]fluorodeoxyglucose (FDG) positron emission tomography imaging and to determine the relation between RV function and FDG uptake in patients with heart failure.
Methods and Results—
A total of 68 patients underwent cardiac [
18
F]FDG positron emission tomography scanning with measurement of RV FDG uptake as a standardized uptake value. Perfusion imaging was acquired at rest with rubidium-82 or [
13
N]ammonia. RV function was determined by equilibrium radionuclide ventriculography. Relative RV FDG uptake was determined as the ratio of RV to LV standardized uptake value. Fifty-five percent of these patients had ischemic cardiomyopathy. The mean LV and RV ejection fractions were 21±7% and 35±10%, respectively. There was a correlation between RV ejection fraction and the ratio of RV to LV FDG uptake whether the entire LV myocardium (
r
=−0.40,
P
<0.001) or LV free wall (
r
=−0.43,
P
<0.001) was used. This relation persisted in the subgroup with nonischemic cardiomyopathy (
r
=−0.37,
P
=0.04). RV FDG uptake was weakly related to increased RV systolic pressure but not related to LV size, function, or FDG uptake. The correlation between RV ejection fraction and RV/LV FDG was maintained after partial-volume correction (
r
=−0.68,
P
<0.001).
Conclusions—
RV dysfunction is associated with an increase in RV FDG uptake, the magnitude of which may be correlated with severity.
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Affiliation(s)
- Lisa M. Mielniczuk
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - David Birnie
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Maria C. Ziadi
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Robert A. deKemp
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Jean N. DaSilva
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Ian Burwash
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Anthony T. Tang
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Ross A. Davies
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Haissam Haddad
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Ann Guo
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - May Aung
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Kathryn Williams
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Heikki Ukkonen
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
| | - Rob S.B. Beanlands
- From the Division of Cardiology (L.M.M., D.BM.C.Z., R.A.d.K., J.N.D.S., I.B., R.A.D., H.H., A.G., M.A., K.W., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, and Division of Cardiology (A.T.T.), University of Victoria, Victoria, Canada; and Division of Cardiology (H.U.), Turku University Hospital, Turku, Finland
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Abstract
Pulmonary arterial hypertension (PAH) is a common problem in adult patients with congenital heart disease. We review available data on aetiology, clinical presentation, prognosis and management of PAH in this setting. In addition, we discuss general management strategies and emerging disease-targeting therapies.
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Affiliation(s)
- G-P Diller
- Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Centre (EMAH Zentrum), University Hospital Muenster, University of Muenster, Muenster, Germany.
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207
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Hill KD, Lim DS, Everett AD, Ivy DD, Moore JD. Assessment of pulmonary hypertension in the pediatric catheterization laboratory: current insights from the Magic registry. Catheter Cardiovasc Interv 2010; 76:865-73. [PMID: 20549685 PMCID: PMC3116922 DOI: 10.1002/ccd.22693] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess protocols, demographics, and hemodynamics in pediatric patients undergoing catheterization for pulmonary hypertension (PH). BACKGROUND Pediatric specific data is limited on PH. METHODS Review of the Mid-Atlantic Group of Interventional Cardiology (MAGIC) collaboration PH registry dataset. RESULTS Between November 2003 and October 2008, seven institutions submitted data from 177 initial catheterizations in pediatric patients with suspected PH. Pulmonary arterial hypertension associated with congenital heart disease (APAH-CHD) (n = 61, 34%) was more common than idiopathic PAH (IPAH) (n = 36, 20%). IPAH patients were older with higher mean pulmonary arterial pressures (mPAP) (P < 0.01). Oxygen lowered mPAP in patients with IPAH (P < 0.01) and associated PAH not related to congenital heart disease (APAH-non CHD) (P < 0.01). A synergistic effect was seen with inhaled nitric oxide (iNO) (P < 0.01). Overall 9/30 (29%) patients with IPAH and 8/48 (16%) patients with APAH-non CHD were reactive to vasodilator testing. Oxygen lowered pulmonary vascular resistance index (PVRI) in patients with APAH-CHD (P < 0.01). There was no additive effect with iNO but a subset of patients required iNO to lower PVRI below 5 WU·m(2). General anesthesia (GA) lowered systemic arterial pressure (P < 0.01) with no difference between GA and procedural sedation on mPAP or PVRI. Adverse events were rare (n = 7) with no procedural deaths. CONCLUSIONS Pediatric patients with PH demonstrate a higher incidence of APAH-CHD and neonatal specific disorders compared to adults. Pediatric PH patients may demonstrate baseline mPAP < 40 mm Hg but > 50% systemic illustrating the difficulty in applying adult criteria to children with PH. Catheterization in children with PH is relatively safe.
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Affiliation(s)
- Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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208
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Chatterjee S. Pulmonary hypertension in systemic sclerosis. Semin Arthritis Rheum 2010; 41:19-37. [PMID: 21047671 DOI: 10.1016/j.semarthrit.2010.08.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 07/04/2010] [Accepted: 08/18/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To discuss the clinical subtypes, pathogenesis, pathology, diagnostic evaluation, treatment options, and prognosis of pulmonary hypertension in systemic sclerosis (SSc-PH) and highlight its fundamental differences from idiopathic pulmonary arterial hypertension (IPAH). METHODS A Medline search for articles published between January 1969 and June 2010 was conducted using the following keywords: scleroderma, systemic sclerosis, pulmonary hypertension, pulmonary arterial hypertension, pulmonary veno-occlusive disease, pathogenesis, pathology, investigation, treatment, and prognosis. The essential differences from IPAH in pathogenesis and histopathologic findings were highlighted and the limitations of some of the investigations used were emphasized. The differences in response to currently accepted therapy and prognosis were also reviewed. RESULTS In scleroderma, pulmonary hypertension can be present in isolation or along with interstitial lung disease and left heart disease. In SSc-PH, the unique histopathologic findings in the lungs include intimal fibrosis, absence of plexiform lesions, and a high prevalence of pulmonary veno-occlusive disease-like lesions. Both "6-minute walk test" and NT-proBNP have their limitations in the evaluation of SSc-PH. For treatment, calcium channel blockers are ineffective and anticoagulation should be used with caution. Currently approved therapies are not as effective and prognosis is much worse in SSc-PH compared with IPAH. CONCLUSIONS SSc-PH is a complex condition with poorer response to therapy and worse outcome compared with that of IPAH. Recent findings have shed some light about the pathophysiology and pathogenesis of SSc-PH. Further research in this area is warranted to better understand the complex pathogenesis and devise better therapeutic strategies.
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Affiliation(s)
- Soumya Chatterjee
- Department of Rheumatic and Immunologic Diseases, Orthopedic and Rheumatology Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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209
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Swiston JR, Johnson SR, Granton JT. Factors that prognosticate mortality in idiopathic pulmonary arterial hypertension: A systematic review of the literature. Respir Med 2010; 104:1588-607. [DOI: 10.1016/j.rmed.2010.08.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 07/28/2010] [Accepted: 08/09/2010] [Indexed: 10/19/2022]
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210
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van Wolferen SA, van de Veerdonk MC, Mauritz GJ, Jacobs W, Marcus JT, Marques KMJ, Bronzwaer JGF, Heymans MW, Boonstra A, Postmus PE, Westerhof N, Vonk Noordegraaf A. Clinically significant change in stroke volume in pulmonary hypertension. Chest 2010; 139:1003-1009. [PMID: 20864614 DOI: 10.1378/chest.10-1066] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Stroke volume is probably the best hemodynamic parameter because it reflects therapeutic changes and contains prognostic information in pulmonary hypertension (PH). Stroke volume directly reflects right ventricular function in response to its load, without the correction of compensatory increased heart rate as is the case for cardiac output. For this reason, stroke volume, which can be measured noninvasively, is an important hemodynamic parameter to monitor during treatment. However, the extent of change in stroke volume that constitutes a clinically significant change is unknown. The aim of this study was to determine the minimal important difference (MID) in stroke volume in PH. METHODS One hundred eleven patients were evaluated at baseline and after 1 year of follow-up with a 6-min walk test (6MWT) and cardiac MRI. Using the anchor-based method with 6MWT as the anchor, and the distribution-based method, the MID of stroke volume change could be determined. RESULTS After 1 year of treatment, there was, on average, a significant increase in stroke volume and 6MWT. The change in stroke volume was related to the change in 6MWT. Using the anchor-based method, an MID of 10 mL in stroke volume was calculated. The distribution-based method resulted in an MID of 8 to 12 mL. CONCLUSIONS Both methods showed that a 10-mL change in stroke volume during follow-up should be considered as clinically relevant. This value can be used to interpret changes in stroke volume during clinical follow-up in PH.
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Affiliation(s)
- Serge A van Wolferen
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Gert-Jan Mauritz
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands
| | - Wouter Jacobs
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands
| | - J Tim Marcus
- Department of Physics and Medical Technology, Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Koen M J Marques
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jean G F Bronzwaer
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Anco Boonstra
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands
| | - Pieter E Postmus
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands
| | - Nico Westerhof
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Disease, VU University Medical Center, Amsterdam, The Netherlands.
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211
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Effects of a Rehabilitation Program on Skeletal Muscle Function in Idiopathic Pulmonary Arterial Hypertension. J Cardiopulm Rehabil Prev 2010; 30:319-23. [DOI: 10.1097/hcr.0b013e3181d6f962] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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212
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Leszek P, Klisiewicz A, Janas J, Różański J, Rywik T, Piotrowski W, Korewicki J. Determinants of the reduction in B-type natriuretic peptide after mitral valve replacement in patients with rheumatic mitral stenosis. Clin Physiol Funct Imaging 2010; 30:473-9. [DOI: 10.1111/j.1475-097x.2010.00968.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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213
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Analysis of the Lung Allocation Score Estimation of Risk of Death in Patients With Pulmonary Arterial Hypertension Using Data From the REVEAL Registry. Transplantation 2010; 90:298-305. [DOI: 10.1097/tp.0b013e3181e49b83] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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214
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Prevalence of acute vasoresponsiveness in patients with pulmonary hypertension: treatment implications. South Med J 2010; 103:630-4. [PMID: 20531064 DOI: 10.1097/smj.0b013e3181e1a8af] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) is a serious and often progressive disorder that results in right ventricular dysfunction. The general reported rate of patients who are responders is 10%-26%. More recently, using the current criteria, the rate of acute vasodilator response was as low as 6%. This study used the most current guidelines to assess the prevalence of acute vasoresponsiveness in patients with PH. METHODS A retrospective chart review of 618 patients seen in the PH clinic at the Mayo Clinic Jacksonville from 1991 to June 2008 was conducted. We assessed the prevalence of acute vasoresponsiveness in patients with PH who had undergone vasodilator trial with epoprostenol or nitric oxide, using the current accepted criteria. RESULTS One hundred and seventy-six patients who underwent a vasodilator trial that had complete hemodynamic data were identified. The average age was 61 +/- 14 years and most were women (67%). The PH was severe with most patients in the World Health Organization (WHO) functional class III-IV (82%), and an average mean pulmonary artery pressure of 48 +/- 11 mm Hg. Although the study group included all WHO diagnostic groups, 69% were diagnosed as Group I pulmonary arterial hypertension. We found an overall prevalence of response to acute vasodilator therapy to be 26%. CONCLUSION Using the most current criteria to identify acute responders to vasodilator therapy in PH patients, we found a slightly higher rate of "responders" than previously reported. Acute vasodilator testing identifies a clinically important group who may benefit from calcium channel blockers (CCBs), and this study confirms that a significant percentage of PH patients are acutely vasoresponsive.
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215
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Reichenberger F, Mainwood A, Morrell NW, Parameshwar J, Pepke-Zaba J. Intravenous epoprostenol versus high dose inhaled iloprost for long-term treatment of pulmonary hypertension. Pulm Pharmacol Ther 2010; 24:169-73. [PMID: 20601049 DOI: 10.1016/j.pupt.2010.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 05/17/2010] [Accepted: 06/18/2010] [Indexed: 01/12/2023]
Abstract
BACKGROUND Intravenous prostacyclin (iv PGI) and inhaled Iloprost (inh ilo) are established therapies in pulmonary arterial hypertension (PAH), however comparative data are lacking. METHODS AND PATIENTS We performed a long-term open label comparison trial of iv PGI or high dose inh ilo in 24 patients with severe PAH: 12 patients (9 female, 40 +/- 14 years, 10 idiopathic PAH, 2 PAH in connective tissue disease CTD) received iv PGI, whereas 12 patients (7 female, 43 +/- 12 years, 5 IPAH, 6 CTD, 1 porto-pulmonary hypertension) were commenced on inh ilo with a median dose of 120 μg/24 h. Haemodynamic parameters and 6 min walking distance (6MWD) at baseline did not differ between both groups. RESULTS After 3 months therapy, patients on iv PGI showed a significant increase in 6MWD from 220 to 280 m (p < 0.01), whereas patients on high dose inh ilo increased 6MWD from 200 to 275 m (p < 0.05). The event free follow up was 23 [1-76] months in the iv PGI2I group, and 16 [7-38] months in the high dose inh ilo group (p < 0.05). Patients with a 6MWD ≥ 300 m after 3 months therapy had a significantly longer event free follow up [16 vs. 35 months; p < 0.004]. CONCLUSION In this patient population with severe pulmonary hypertension of different etiologies, event free follow up on treatment with iv PGI is significantly longer compared to high dose inh ilo. The 6MWD after 3 months treatment might be predictive for long term outcome.
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Affiliation(s)
- Frank Reichenberger
- Pulmonary Vascular Diseases Unit Papworth Hospital, Cambridge, United Kingdom.
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216
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López-Candales A, Edelman K, Gulyasy B, Candales MD. New Annular Tissue Doppler Markers of Pulmonary Hypertension. Echocardiography 2010; 27:969-76. [DOI: 10.1111/j.1540-8175.2010.01176.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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217
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Kind T, Mauritz GJ, Marcus JT, van de Veerdonk M, Westerhof N, Vonk-Noordegraaf A. Right ventricular ejection fraction is better reflected by transverse rather than longitudinal wall motion in pulmonary hypertension. J Cardiovasc Magn Reson 2010; 12:35. [PMID: 20525337 PMCID: PMC2901360 DOI: 10.1186/1532-429x-12-35] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 06/04/2010] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Longitudinal wall motion of the right ventricle (RV), generally quantified as tricuspid annular systolic excursion (TAPSE), has been well studied in pulmonary hypertension (PH). In contrast, transverse wall motion has been examined less. Therefore, the aim of this study was to evaluate regional RV transverse wall motion in PH, and its relation to global RV pump function, quantified as RV ejection fraction (RVEF). METHODS In 101 PH patients and 29 control subjects cardiovascular magnetic resonance was performed. From four-chamber cine imaging, RV transverse motion was quantified as the change of the septum-free-wall (SF) distance between end-diastole and end-systole at seven levels along an apex-to-base axis. For each level, regional absolute and fractional transverse distance change (SFD and fractional-SFD) were computed and related to RVEF. Longitudinal measures, including TAPSE and fractional tricuspid-annulus-apex distance change (fractional-TAAD) were evaluated for comparison. RESULTS Transverse wall motion was significantly reduced at all levels compared to control subjects (p < 0.001). For all levels, fractional-SFD and SFD were related to RVEF, with the strongest relation at mid RV (R(2) = 0.70, p < 0.001 and R(2) = 0.62, p < 0.001). For TAPSE and fractional-TAAD, weaker relations with RVEF were found (R(2) = 0.21, p < 0.001 and R(2) = 0.27, p < 0.001). CONCLUSIONS Regional transverse wall movements provide important information of RV function in PH. Compared to longitudinal motion, transverse motion at mid RV reveals a significantly stronger relationship with RVEF and thereby might be a better predictor for RV function.
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Affiliation(s)
- Taco Kind
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands
| | - Gert-Jan Mauritz
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands
| | - J Tim Marcus
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Nico Westerhof
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands
- Department of Physiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands
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Hartman JC, Brouwer K, Mandagere A, Melvin L, Gorczynski R. Evaluation of the endothelin receptor antagonists ambrisentan, darusentan, bosentan, and sitaxsentan as substrates and inhibitors of hepatobiliary transporters in sandwich-cultured human hepatocytesThis article is one of a selection of papers published in the two-part special issue entitled 20 Years of Endothelin Research. Can J Physiol Pharmacol 2010; 88:682-91. [DOI: 10.1139/y10-060] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
To evaluate potential mechanisms of clinical hepatotoxicity, 4 endothelin receptor antagonists (ERAs) were examined for substrate activity and inhibition of hepatic uptake and efflux transporters in sandwich-cultured human hepatocytes. The 4 transporters studied were sodium-dependent taurocholate cotransporter (NTCP), organic anion transporter (OATP), bile salt export pump (BSEP), and multidrug resistance-associated protein 2 (MRP2). ERA transporter inhibition was examined using the substrates taurocholate (for NTCP and BSEP), [3H]estradiol-17β-d-glucuronide (for OATP), and [2-d-penicillamine, 5-d-penicillamine]enkephalin (for MRP2). ERA substrate activity was evaluated using probe inhibitors ritonavir (OATP and BSEP), bromosulfalein (OATP), erythromycin (P-glycoprotein), probenecid (MRP2 and OATP), and cyclosporin (NTCP). ERAs were tested at 2, 20, and 100 µmol·L–1 for inhibition and at 2 µmol·L–1 as substrates. OATP, NTCP, or BSEP transport activity was not reduced by ambrisentan or darusentan. Bosentan and sitaxsentan attenuated NTCP transport at higher concentrations. Only sitaxsentan decreased OATP transport (52%), and only bosentan reduced BSEP transport (78%). MRP2 transport activity was unaltered. OATP inhibitors decreased influx of all ERAs. Darusentan influx was least affected (84%–100% of control), whereas bosentan was most affected (32%–58% of control). NTCP did not contribute to influx of ERAs. Only bosentan and darusentan were shown as substrates for both BSEP and P-glycoprotein efflux. All ERAs tested were substrates for at least one hepatic transporter. Bosentan and sitaxsentan, but not ambrisentan and darusentan, inhibited human hepatic transporters, which provides a potential mechanism for the increased hepatotoxicity observed for these agents in the clinical setting.
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Affiliation(s)
- J. Craig Hartman
- Gilead Sciences Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
- Qualyst Inc., 2810 Meridian Parkway, Suite 100, Durham, NC 27713, USA
| | - Kenneth Brouwer
- Gilead Sciences Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
- Qualyst Inc., 2810 Meridian Parkway, Suite 100, Durham, NC 27713, USA
| | - Arun Mandagere
- Gilead Sciences Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
- Qualyst Inc., 2810 Meridian Parkway, Suite 100, Durham, NC 27713, USA
| | - Lawrence Melvin
- Gilead Sciences Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
- Qualyst Inc., 2810 Meridian Parkway, Suite 100, Durham, NC 27713, USA
| | - Richard Gorczynski
- Gilead Sciences Inc., 333 Lakeside Drive, Foster City, CA 94404, USA
- Qualyst Inc., 2810 Meridian Parkway, Suite 100, Durham, NC 27713, USA
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Litwin SE. Noninvasive assessment of pulmonary artery pressures: moving beyond tricuspid regurgitation velocities. Circ Cardiovasc Imaging 2010; 3:132-3. [PMID: 20233861 DOI: 10.1161/circimaging.110.945121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Burger CD, Zeiger T. What Can be Learned in 6 Minutes? 6-Minute Walk Test Primer and Role in Pulmonary Arterial Hypertension. ACTA ACUST UNITED AC 2010. [DOI: 10.21693/1933-088x-9.2.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The 6-minute walk test is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension. The correlation with maximal cardiac output renders the test an indirect measure of right ventricular function in patients with significant pulmonary arterial hypertension. The test has been employed in the majority of studies evaluating the efficacy of pulmonary arterial vasodilators. In addition, the distance walked has been demonstrated to correlate with prognosis. An understanding of the 6-minute walk test indications, logistics, limitations, and interpretation is important to the clinician utilizing this test to evaluate patients with pulmonary arterial hypertension.
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Affiliation(s)
- Charles D. Burger
- Chair, Pulmonary and Critical Care Medicine, Associate Professor of Medicine, Mayo Clinic Florida, Jacksonville, Florida
| | - Tonya Zeiger
- Coordinator, Pulmonary, Hypertension Clinic, Mayo Clinic Florida, Jacksonville, Florida
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Simon MA, Rajagopalan N, Mathier MA, Shroff SG, Pinsky MR, López-Candales A. Tissue Doppler imaging of right ventricular decompensation in pulmonary hypertension. ACTA ACUST UNITED AC 2010; 15:271-6. [PMID: 19925505 DOI: 10.1111/j.1751-7133.2009.00113.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Right ventricular (RV) function is closely linked to outcomes in pulmonary hypertension (PH). The authors sought to evaluate RV myocardial strain in 3 groups of patients: normal, PH with compensated RV function (PH-C), and PH with decompensated RV function (PH-D). Fifty-six patients (aged 56+/-12 years; 40 women; mean pulmonary artery pressure [MPAP] range, 13-82 mm Hg) underwent right heart catheterization and 2-dimensional echocardiography with tissue Doppler imaging of the RV. Right atrial pressures were 6+/-3, 5+/-2, and 14+/-4 mm Hg; MPAP values were 19+/-3, 44+/-15, and 56+/-13 mm Hg; pulmonary vascular resistances were 1.4+/-0.4, 7.9+/-5.1, and 11.5+/-6.6 Wood units; and cardiac indices were 3.4+/-0.9, 2.8+/-0.8, and 2.2+/-0.7 L/min/m(2) (P<.05 for all for normal, PH-C, and PH-D patients), respectively. RV free wall strain decreased significantly among all 3 groups (-26%+/-6%, -19%+/-7%, and -14%+/-5%; P<.0001). RV free wall strain decreases in PH without hemodynamically decompensated RV function suggesting it may be a preceding step in the development of RV failure. This may be of particular use in following patients sequentially.
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Affiliation(s)
- Marc A Simon
- Cardiovascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Campo A, Mathai SC, Le Pavec J, Zaiman AL, Hummers LK, Boyce D, Housten T, Champion HC, Lechtzin N, Wigley FM, Girgis RE, Hassoun PM. Hemodynamic predictors of survival in scleroderma-related pulmonary arterial hypertension. Am J Respir Crit Care Med 2010; 182:252-60. [PMID: 20339143 DOI: 10.1164/rccm.200912-1820oc] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Pulmonary arterial hypertension (PAH) related to systemic sclerosis (SSc) has a poorer prognosis compared with other forms of PAH for reasons that remain unexplained. OBJECTIVES To identify risk factors of mortality in a well-characterized cohort of patients with PAH related to systemic sclerosis (SSc-PAH). METHODS Seventy-six consecutive patients with SSc (64 women and 12 men; mean age 61 +/- 11 yr) were diagnosed with PAH by heart catheterization in a single center, starting in January 2000, and followed over time. Kaplan-Meier estimates were calculated and mortality risk factors were analyzed. MEASUREMENTS AND MAIN RESULTS Forty (53%) patients were in World Health Organization functional class III or IV. Mean pulmonary artery pressure was 41 +/- 11 mm Hg, pulmonary vascular resistance (PVR) was 8.6 +/- 5.6 Wood units, and cardiac index was 2.4 +/- 0.7 L/min/m(2). Median follow-up time was 36 months, with 42 deaths observed. Survival estimates were 85%, 72%, 67%, 50%, and 36% at 1, 2, 3, 4, and 5 years, respectively. Multivariate analysis identified PVR (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03-1.18; P < 0.01), stroke volume index (HR, 0.94; 95% CI, 0.89-0.99; P = 0.02), and pulmonary arterial capacitance (HR, 0.43; 95% CI, 0.20-0.91; P = 0.03) as strong predictors of survival. An estimated glomerular filtration rate less than 60 ml/min/1.73 m(2) portended a threefold risk of mortality. CONCLUSIONS Our results suggest that specific components of right ventricular dysfunction and renal impairment contribute to increased mortality in SSc-PAH. Understanding the mechanisms of right ventricular dysfunction in response to increased afterload should lead to improved targeted therapy in these patients.
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Affiliation(s)
- Aránzazu Campo
- MD, Division of Pulmonary and Critical Care Medicine, 1830 E Monument St, Fifth Floor, Baltimore, MD 21205, USA
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Ilsar R, Chawantanpipat C, Chan KH, Dobbins TA, Waugh R, Hennessy A, Celermajer DS, Ng MKC. Measurement of pulmonary flow reserve and pulmonary index of microcirculatory resistance for detection of pulmonary microvascular obstruction. PLoS One 2010; 5:e9601. [PMID: 20231900 PMCID: PMC2834756 DOI: 10.1371/journal.pone.0009601] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 02/16/2010] [Indexed: 11/18/2022] Open
Abstract
Background The pulmonary microcirculation is the chief regulatory site for resistance in the pulmonary circuit. Despite pulmonary microvascular dysfunction being implicated in the pathogenesis of several pulmonary vascular conditions, there are currently no techniques for the specific assessment of pulmonary microvascular integrity in humans. Peak hyperemic flow assessment using thermodilution-derived mean transit-time (Tmn) facilitate accurate coronary microcirculatory evaluation, but remain unvalidated in the lung circulation. Using a high primate model, we aimed to explore the use of Tmn as a surrogate of pulmonary blood flow for the purpose of measuring the novel indices Pulmonary Flow Reserve [PFR = (maximum hyperemic)/(basal flow)] and Pulmonary Index of Microcirculatory Resistance [PIMR = (maximum hyperemic distal pulmonary artery pressure)×(maximum hyperemic Tmn)]. Ultimately, we aimed to investigate the effect of progressive pulmonary microvascular obstruction on PFR and PIMR. Methods and Results Temperature- and pressure-sensor guidewires (TPSG) were placed in segmental pulmonary arteries (SPA) of 13 baboons and intravascular temperature measured. Tmn and hemodynamics were recorded at rest and following intra-SPA administration of the vasodilator agents adenosine (10–400 µg/kg/min) and papaverine (3–24 mg). Temperature did not vary with intra-SPA sensor position (0.010±0.009 v 0.010±0.009°C; distal v proximal; p = 0.1), supporting Tmn use in lung for the purpose of hemodynamic indices derivation. Adenosine (to 200 µg/kg/min) & papaverine (to 24 mg) induced dose-dependent flow augmentations (40±7% & 35±13% Tmn reductions v baseline, respectively; p<0.0001). PFR and PIMR were then calculated before and after progressive administration of ceramic microspheres into the SPA. Cumulative microsphere doses progressively reduced PFR (1.41±0.06, 1.26±0.19, 1.17±0.07 & 1.01±0.03; for 0, 104, 105 & 106 microspheres; p = 0.009) and increased PIMR (5.7±0.6, 6.3±1.0, 6.8±0.6 & 7.6±0.6 mmHg.sec; p = 0.0048). Conclusions Thermodilution-derived mean transit time can be accurately and reproducibly measured in the pulmonary circulation using TPSG. Mean transit time-derived PFR and PIMR can be assessed using a TPSG and adenosine or papaverine as hyperemic agents. These novel indices detect progressive pulmonary microvascular obstruction and thus have with a potential role for pulmonary microcirculatory assessment in humans.
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Affiliation(s)
- Rahn Ilsar
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | | | - Kim H. Chan
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Timothy A. Dobbins
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Richard Waugh
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | | - David S. Celermajer
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Martin K. C. Ng
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
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Lopez-Candales A, Eleswarapu A, Shaver J, Edelman K, Gulyasy B, Candales MD. Right ventricular outflow tract spectral signal: a useful marker of right ventricular systolic performance and pulmonary hypertension severity. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:509-15. [DOI: 10.1093/ejechocard/jeq009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
PURPOSE OF REVIEW Systemic sclerosis is commonly complicated by pulmonary arterial hypertension (PAH-SSc) and is a leading cause of death in this population. We will review existing challenges and recent advances in the treatment of this disease. RECENT FINDINGS Traditionally employed outcome measures in pulmonary arterial hypertension research may not be applicable in PAH-SSc. Importantly, new therapies that target abnormal cellular proliferation in the pulmonary vasculature are currently under investigation and may be particularly relevant to PAH-SSc. SUMMARY Pulmonary arterial hypertension complicating systemic sclerosis occurs commonly and portends a poor prognosis. However, recent advances in our understanding of the disease in the context of systemic sclerosis may lead to novel diagnostic and therapeutic strategies that will ultimately improve quality of life and survival in this population.
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Diagnostic strategies for acute presentation of pulmonary hypertension in children: particular focus on use of echocardiography, cardiac catheterization, magnetic resonance imaging, chest computed tomography, and lung biopsy. Pediatr Crit Care Med 2010; 11:S23-6. [PMID: 20216157 DOI: 10.1097/pcc.0b013e3181c7683a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Determining the etiology of pediatric pulmonary hypertension is essential to appropriate management. Assessment of the patient requires complete history and physical examination as well as the use of investigative modalities including echocardiography, cardiac catheterization, cardiac magnetic resonance imaging (MRI), chest computed tomography, and lung biopsy. This review summarizes recommendations for diagnostic work-up and includes a clinical algorithm for evaluation of the patient with acute pulmonary hypertension in the pediatric intensive care unit.
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Brierre G, Blot-Souletie N, Degano B, Tetu L, Bongard V, Carrie D. New echocardiographic prognostic factors for mortality in pulmonary arterial hypertension. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:516-22. [DOI: 10.1093/ejechocard/jeq011] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Steele P, Strange G, Wlodarczyk J, Dalton B, Stewart S, Gabbay E, Keogh A. Hemodynamics in pulmonary arterial hypertension (PAH): do they explain long-term clinical outcomes with PAH-specific therapy? BMC Cardiovasc Disord 2010; 10:9. [PMID: 20170553 PMCID: PMC2841582 DOI: 10.1186/1471-2261-10-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 02/22/2010] [Indexed: 12/03/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) has witnessed dramatic treatment advances over the past decade. However, with the exception of epoprostenol, data from short-term randomized controlled trials (RCTs) have not shown a benefit of these drugs on survival. There remains a need to differentiate between available therapies and current endpoint responses which in turn, could be used to guide treatment selection and provide long-term prognostic information for patients. Methods We performed a systematic literature search of MEDLINE and EMBASE databases for RCTs of PAH-specific therapy published between January 1980 and May 2009. Articles were selected if they contained a placebo comparator and described hemodynamic changes from baseline. We applied the weighted mean change in hemodynamic variables to the equation developed by the National Institutes of Health (NIH) Registry to estimate long-term survival with each therapy. Results Ten RCTs involving 1,635 patients met the inclusion criteria. Suitable hemodynamic data were identified for bosentan, sitaxentan, sildenafil, epoprostenol, beraprost and treprostinil. 77.6% of patients were female and the mean (SD) age was 46.5 ± 4.9 years. 55.5% of patients had idiopathic PAH (iPAH), 23.9% PAH related to connective tissue disease, and 18.2% PAH related to congenital heart disease. Based on the effects observed in short-term trials and, relative to placebo, all analyzed therapies improved survival. The estimated 1-year survival was 78.4%, 77.8%, 76.1%, 75.8%, 75.2%, and 74.1% for epoprostenol, bosentan, treprostinil, sitaxentan, sildenafil, and beraprost, respectively. These estimates are considerably lower than the 1-year observed survival reported in several open-label and registry studies with PAH-specific therapies: 88% - 97%. Conclusion When applied to the NIH Registry equation, hemodynamic changes from baseline appear to underestimate the survival benefits observed with long-term PAH therapy.
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Affiliation(s)
- Peter Steele
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia
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Badesch DB, Raskob GE, Elliott CG, Krichman AM, Farber HW, Frost AE, Barst RJ, Benza RL, Liou TG, Turner M, Giles S, Feldkircher K, Miller DP, McGoon MD. Pulmonary Arterial Hypertension. Chest 2010; 137:376-87. [PMID: 19837821 DOI: 10.1378/chest.09-1140] [Citation(s) in RCA: 791] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- David B Badesch
- Divisions of Pulmonary Sciences and Critical Care Medicine, and Cardiology, University of Colorado Denver, Denver, CO, USA.
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Sweiss NJ, Hushaw L, Thenappan T, Sawaqed R, Machado RF, Patel AR, Gomberg-Maitland M, Husain AN, Archer SL. Diagnosis and management of pulmonary hypertension in systemic sclerosis. Curr Rheumatol Rep 2010; 12:8-18. [PMID: 20425528 PMCID: PMC2865259 DOI: 10.1007/s11926-009-0078-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Patients with systemic sclerosis (SSc) can develop pulmonary hypertension (PH; mean pulmonary artery pressure >/= 25 mm Hg) caused by pulmonary arterial hypertension (PAH), left ventricular disease, or pulmonary fibrosis. PAH is a pulmonary vascular disease, the diagnosis of which requires pulmonary capillary wedge pressure less than 15 mm Hg, pulmonary vascular resistance greater than 3 Wood Units, and exclusion of thromboembolism and parenchymal lung disease. Molecular mechanisms underlying PAH-SSc include activation of inflammatory and fibrogenic pathways in the vasculature and right ventricle. Circulating autoantibodies trigger endothelial damage and fibroblast activation. PAH most commonly occurs as a late complication in patients with limited cutaneous disease and anticentromere antibodies. Although echocardiography is a useful screening tool, heart catheterization is required to diagnose PAH before initiating therapy. Prognosis and therapeutic response are worse in PAH-SSc than in other PAH categories (median survival, 1-3 y). Approved therapies include prostacyclins, endothelin antagonists, and phosphodiesterase type 5 inhibitors. Research is needed to define disease mechanisms and develop effective therapies.
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Affiliation(s)
- Nadera J. Sweiss
- Section of Rheumatology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Linda Hushaw
- Section of Rheumatology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Thenappan Thenappan
- Section of Cardiology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Ray Sawaqed
- Cardiothoracic Surgery, Methodist Hospital, 8701 Broadway, Merrillville, IN 46410, USA
| | - Roberto F. Machado
- Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Amit R. Patel
- Section of Cardiology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Mardi Gomberg-Maitland
- Section of Cardiology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Aliya N. Husain
- Section of Pathology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
| | - Stephen L. Archer
- Section of Cardiology, University of Chicago, 5841 South Maryland Avenue (MC6080), Chicago, IL 60637, USA
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Goto K, Arai M, Watanabe A, Hasegawa A, Nakano A, Kurabayashi M. Utility of Echocardiography Versus BNP Level for the Prediction of Pulmonary Arterial Pressure in Patients With Pulmonary Arterial Hypertension. Int Heart J 2010; 51:343-7. [DOI: 10.1536/ihj.51.343] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kosaku Goto
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine
| | - Masashi Arai
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine
| | - Atai Watanabe
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine
| | | | - Akihiko Nakano
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine
| | - Masahiko Kurabayashi
- Department of Medicine and Biological Science, Gunma University Graduate School of Medicine
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Dimopoulos S, Anastasiou-Nana M, Katsaros F, Papazachou O, Tzanis G, Gerovasili V, Pozios H, Roussos C, Nanas J, Nanas S. Impairment of autonomic nervous system activity in patients with pulmonary arterial hypertension: a case control study. J Card Fail 2009; 15:882-9. [PMID: 19944365 DOI: 10.1016/j.cardfail.2009.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Revised: 05/28/2009] [Accepted: 06/01/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronotropic response to exercise (CR) and heart rate recovery (HRR) immediately after exercise are indirect indices of sympathetic and parasympathetic activity, respectively. The aim of this study was to evaluate CR and HRR in patients with pulmonary arterial hypertension (PAH) in relation to disease severity. METHODS AND RESULTS Ten PAH patients (6 females/4 males, mean age: 48+/-12 years) and 10 control subjects matched for age, gender, and body mass index (6 females/4 males, mean age: 46+/-6 years) performed a ramp incremental symptom-limited cardiopulmonary exercise test on a cycle ergometer. Main measurements included heart rate at rest (HR), CR=[(peak HR-resting HR/220-age-resting HR)x100, %], HRR(1)=HR difference from peak exercise to 1minute after, ventilatory efficiency during exercise (VE/VCO(2) slope), peak oxygen uptake (VO(2)p), and the first-degree slope of VO(2) for the first minute of the recovery period (VO(2)/t-slope). PAH patients had a significantly decreased CR (58+/-31 vs 92+/-13, %, P < .001) and HRR(1) (10+/-5 vs 29+/-6, beats/min, P < .001) as well as VO(2)p (11.9+/-3.5 vs 26.9+/-6.6, mL.kg.min) and VO(2)/t-slope (0.2+/-0.1 vs. 0.9+/-0.2, mL.kg.min(2)) compared with controls. CR and HRR(1) correlated well with VO(2)p (r=0.7; P < .001 and r=0.85; P < .001, respectively) and VO(2)/t-slope (r=0.66; P < .001 and r=0.85; P < .001, respectively) and had a significant inverse correlation with VE/VCO(2) slope (r=-0.47; P < .01 and r=-0.77; P < .001, respectively). CONCLUSIONS PAH patients present a significant impairment of CR and HRR(1) in relation to disease severity, indicating profound autonomic nervous system abnormalities.
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Utsunomiya H, Nakatani S, Nishihira M, Kanzaki H, Kyotani S, Nakanishi N, Kihara Y, Kitakaze M. Value of Estimated Right Ventricular Filling Pressure in Predicting Cardiac Events in Chronic Pulmonary Arterial Hypertension. J Am Soc Echocardiogr 2009; 22:1368-74. [DOI: 10.1016/j.echo.2009.08.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Indexed: 11/28/2022]
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237
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Wu SC, Caravita S, Lisi E, Pierini S, Dadone V, Todd SE, Gentile F, Secchi MB. Pulmonary arterial hypertension. Intern Emerg Med 2009; 4:459-70. [PMID: 19504164 DOI: 10.1007/s11739-009-0263-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 05/04/2009] [Indexed: 10/20/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating disease with significant disability and mortality, and it has much higher prevalence than previously thought. During the past 15 years, we have witnessed remarkable advances in our understanding of pathogenesis, in diagnostic process and in the development of disease-specific treatments for PAH. Nowadays, the diagnosis is more clearly defined, non-invasive markers of disease severity can be widely applied, and finally we can adopt evidence-based treatment. Newer drugs availability has resulted in radical change in the management of this disease. The article reviews established approaches to evaluation and treatment of this disorder.
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Affiliation(s)
- Sheng Chin Wu
- Dipartimento Medico, U.O. Medicina Ospedale Bassini, Azienda Ospedaliera ICP, Cinisello Balsamo, MI, Italy
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238
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barberá JA, Beghetti M, Corris P, Gaine S, Simon Gibbs J, Gómez-Sánchez MÁ, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guía de práctica clínica para el diagnóstico y tratamiento de la hipertensión pulmonar. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73130-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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239
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Taylor DA, Abdel-Rahman AA. Novel strategies and targets for the management of hypertension. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2009; 57:291-345. [PMID: 20230765 DOI: 10.1016/s1054-3589(08)57008-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Hypertension, as the sole or comorbid component of a constellation of disorders of the cardiovascular (CV) system, is present in over 90% of all patients with CV disease and affects nearly 74 million individuals in the United States. The number of medications available to treat hypertension has dramatically increased during the past 3 decades to some 50 medications as new targets involved in the normal regulation of blood pressure have been identified, resulting in the development of new agents in those classes with improved therapeutic profiles (e.g., renin-angiotensin-aldosterone system; RAAS). Despite these new agents, hypertension is not adequately managed in approximately 30% of patients, who are compliant with prescriptive therapeutics, suggesting that new agents and/or strategies to manage hypertension are still needed. Some of the newest classes of agents have targeted other components of the RAS, for example, the selective renin inhibitors, but recent advances in vascular biology have provided novel potential targets that may provide avenues for new agent development. These newer targets include downstream signaling participants in pathways involved in contraction, growth, hypertrophy, and relaxation. However, perhaps the most unique approach to the management of hypertension is a shift in strategy of using existing agents with respect to the time of day at which the agent is taken. This new strategy, termed "chronotherapy," has shown considerable promise in effectively managing hypertensive patients. Therefore, there remains great potential for future development of safe and effective agents and strategies to manage a disorder of the CV system of epidemic proportion.
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Affiliation(s)
- David A Taylor
- Department of Pharmacology and Toxicology, Brody School of Medicine at East Carolina University, Greenville, North Carolina 27834, USA
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240
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Garin MC, Clark L, Chumney ECG, Simpson KN, Highland KB. Cost-utility of treatments for pulmonary arterial hypertension: a Markov state-transition decision analysis model. Clin Drug Investig 2009; 29:635-46. [PMID: 19715380 DOI: 10.2165/11317820-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Clinicians must choose between an increasing number of medications for the treatment of pulmonary arterial hypertension (PAH) with different routes of administration, adverse effects, costs and efficacies. We constructed a decision analysis to help inform treatment choices in PAH. METHODS We created a Markov-type model to evaluate 1-year treatment with bosentan, treprostinil, epoprostenol, inhaled iloprost, sildenafil, sitaxentan and ambrisentan. Transition probabilities were based on observed transitions between WHO functional classes, adjusted by relative risk of improvement in a 6-minute walk test. Utilities were based on reported values for each functional class, adjusted for burden of treatment administration. Costs were estimated from Medicare and Medicaid reimbursement data. Sensitivity analyses evaluated changes in efficacy, utilities and costs. RESULTS Treatment with sildenafil was less costly and resulted in a greater gain in quality-adjusted life-years (QALYs) compared with other treatments. Treatment with ambrisentan and bosentan resulted in the same gain in QALYs as sildenafil, but at a higher cost. Sensitivity analyses had minimal impact on these results. CONCLUSIONS Based on this model, sildenafil is a cost-effective treatment for PAH with a low price and a net increase in QALYs. The results from this analysis are a tool to help guide clinicians in deciding which PAH medications to use; however, the final decisions should be individualized because the effectiveness of therapy, resulting utilities and acceptable costs will differ with each patient.
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Affiliation(s)
- Margaret C Garin
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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241
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Minai OA, Ricaurte B, Kaw R, Hammel J, Mansour M, McCarthy K, Golish JA, Stoller JK. Frequency and impact of pulmonary hypertension in patients with obstructive sleep apnea syndrome. Am J Cardiol 2009; 104:1300-6. [PMID: 19840581 DOI: 10.1016/j.amjcard.2009.06.048] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Revised: 06/05/2009] [Accepted: 06/05/2009] [Indexed: 11/19/2022]
Abstract
The correlates and consequences of pulmonary hypertension (PH) associated with obstructive sleep apnea (OSA) are poorly understood. Patients undergoing pulmonary artery catheterization within 6 months of an overnight polysomnography showing OSA were included in the present analysis. A total of 83 patients with complete data were analyzed (no PH, n = 25 [30%]; PH, 58 [70%]; of these, 18 had a pulmonary capillary wedge pressure of <15 mm Hg). No significant differences were observed between the PH and no PH groups regarding age or apnea-hypopnea index. The correlates of PH were elevated right ventricular systolic pressure (p <0.001), body mass index (p = 0.026), female gender (p = 0.01), nocturnal desaturation (82% vs 18%), and forced vital capacity <70% (p = 0.04) on univariate analysis and female gender (p = 0.03), age <49 years (p = 0.02), body mass index of > or =26 kg/m(2) (p = 0.08), and right ventricular systolic pressure of > or =30 mm Hg (p <0.001) on multivariate analysis. Patients with PH had a lower 6-minute walk distance (285.5 +/- 122 m vs 343 +/- 213 m, p = 0.4). The survival rate at 1, 4, and 8 years for patients with PH was 93%, 75%, and 43% compared to 100%, 90%, and 76% for patients without PH, respectively. Patients with severe PH (n = 27; 33%) had more nocturnal desaturation (p = 0.045), worse pulmonary hemodynamics, and greater mortality (37%) than the groups with mild or moderate PH (16%) or no PH (16%). In conclusion, our results have shown that, although generally mild to moderate, severe PH can occur in patients with OSA. Female gender, younger age, obesity, and nocturnal desaturation were associated with PH. PH can cause functional limitations and increased mortality in patients with OSA.
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Affiliation(s)
- Omar A Minai
- Respiratory Institute, Cleveland Clinic, Ohio, USA.
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242
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Amabile N, Heiss C, Chang V, Angeli FS, Damon L, Rame EJ, McGlothlin D, Grossman W, De Marco T, Yeghiazarians Y. Increased CD62e+ Endothelial Microparticle Levels Predict Poor Outcome in Pulmonary Hypertension Patients. J Heart Lung Transplant 2009; 28:1081-6. [DOI: 10.1016/j.healun.2009.06.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Revised: 06/10/2009] [Accepted: 06/12/2009] [Indexed: 12/31/2022] Open
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243
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Hampole CV, Mehrotra AK, Thenappan T, Gomberg-Maitland M, Shah SJ. Usefulness of red cell distribution width as a prognostic marker in pulmonary hypertension. Am J Cardiol 2009; 104:868-72. [PMID: 19733726 DOI: 10.1016/j.amjcard.2009.05.016] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 05/10/2009] [Accepted: 05/10/2009] [Indexed: 12/20/2022]
Abstract
Red blood cell distribution width (RDW), a widely available biomarker, independently predicts adverse outcomes in left-sided heart failure. The relation between RDW and death in pulmonary hypertension (PH) is unknown. In a prospective study of 162 consecutive patients with PH, RDW was recorded during initial diagnostic right-sided cardiac catheterization, and patients were followed for 2.1 +/- 0.8 years to determine vital status. Demographic, clinical, laboratory, and hemodynamic variables were compared by tertile of RDW. Cox proportional-hazards models were used to determine whether RDW was independently associated with death, and the prognostic utility of RDW was compared to that of other laboratory predictors, including N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP). Of the 162 study patients, 78% were women, and 62% had pulmonary arterial hypertension. The mean age was 53 +/- 15 years, and most patients had severe PH (mean pulmonary artery pressure 48 +/- 13 mm Hg). The highest tertile of RDW predicted death (univariate hazard ratio 4.86, 95% confidence interval 1.37 to 17.29, p = 0.015; multivariate hazard ratio 2.4, 95% confidence interval 1.02 to 5.84, p = 0.045, after adjusting for age, gender, diabetes mellitus, connective tissue disease, diuretic use, phosphodiesterase inhibitor use, hemoglobin, mean corpuscular volume, and blood urea nitrogen [BUN]). Of the laboratory data, only RDW, BUN, and NT-pro-BNP were associated with death on univariate analysis. When RDW, BUN, and NT-pro-BNP were entered into a multivariate model, only RDW was still associated with death (p = 0.037 for RDW, p = 0.18 for BUN, and p = 0.39 for NT-pro-BNP). Adding NT-pro-BNP to RDW did not improve the prediction of mortality. In conclusion, RDW is independently associated with death in patients with PH and performs better as a prognostic indicator than NT-pro-BNP.
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244
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Stevens GR, Lala A, Sanz J, Garcia MJ, Fuster V, Pinney S. Exercise Performance in Patients With Pulmonary Hypertension Linked to Cardiac Magnetic Resonance Measures. J Heart Lung Transplant 2009; 28:899-905. [DOI: 10.1016/j.healun.2009.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 04/23/2009] [Accepted: 05/02/2009] [Indexed: 10/20/2022] Open
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245
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, Beghetti M, Corris P, Gaine S, Gibbs JS, Gomez-Sanchez MA, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30:2493-537. [PMID: 19713419 DOI: 10.1093/eurheartj/ehp297] [Citation(s) in RCA: 2205] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nazzareno Galiè
- Institute of Cardiology, Bologna University Hospital, Via Massarenti, 9, 40138 Bologna, Italy.
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246
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Affiliation(s)
- Reda E. Girgis
- Associate Professor, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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247
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Kravitz JN, Strange C. How should we treat vascular and fibrotic lung disease in scleroderma? F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948723 PMCID: PMC2948303 DOI: 10.3410/m1-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent randomized trials suggest that evidence-based algorithms for systemic sclerosis can be developed to identify patients at risk for lung disease, follow lung disease progression, and modify disease with therapies of proven benefit. Recognition of disease subsets allows physicians to integrate physiology, overlapping disease manifestations, and predictable drug effects into a comprehensive disease management program.
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Affiliation(s)
- Jared N Kravitz
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina 96 Jonathan Lucas St, Suite 812 CSB, Charleston, SC 29425 USA
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248
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Badesch DB, Champion HC, Gomez Sanchez MA, Hoeper MM, Loyd JE, Manes A, McGoon M, Naeije R, Olschewski H, Oudiz RJ, Torbicki A. Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 2009; 54:S55-S66. [PMID: 19555859 DOI: 10.1016/j.jacc.2009.04.011] [Citation(s) in RCA: 741] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 04/15/2009] [Indexed: 12/23/2022]
Abstract
The diagnosis and assessment of pulmonary arterial hypertension is a rapidly evolving area, with changes occurring in the definition of the disease, screening and diagnostic techniques, and staging and follow-up assessment. The definition of pulmonary hypertension has been simplified, and is now based on currently available evidence. There has been substantial progress in advancing the imaging techniques and biomarkers used to screen patients for the disease and to follow up their response to therapy. The importance of accurate assessment of right ventricular function in following up the clinical course and response to therapy is more fully appreciated. As new therapies are developed for pulmonary arterial hypertension, screening, prompt diagnosis, and accurate assessment of disease severity become increasingly important. A clear definition of pulmonary hypertension and the development of a rational approach to diagnostic assessment and follow-up using both conventional and new tools will be essential to deriving maximal benefit from our expanding therapeutic armamentarium.
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Affiliation(s)
- David B Badesch
- Divisions of Pulmonary Sciences and Critical Care Medicine and Cardiology, University of Colorado Health Sciences Center, Denver, Colorado.
| | - Hunter C Champion
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
| | | | - Marius M Hoeper
- Department of Respiratory Medicine, University of Hannover Medical School, Hannover, Germany
| | - James E Loyd
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | - Robert Naeije
- Departments of Pathophysiology and Cardiology, Erasme Academic Hospital, Free University of Brussels, Brussels, Belgium
| | - Horst Olschewski
- Pulmonology Division, University Clinic of Internal Medicine, Medical University Graz, Graz, Austria
| | - Ronald J Oudiz
- Liu Center for Pulmonary Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Adam Torbicki
- Department of Chest Medicine, Institute of Tuberculosis and Lung Diseases, Medical University of Warsaw, Warsaw, Poland
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249
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McLaughlin V, Humbert M, Coghlan G, Nash P, Steen V. Pulmonary arterial hypertension: the most devastating vascular complication of systemic sclerosis. Rheumatology (Oxford) 2009; 48 Suppl 3:iii25-31. [PMID: 19487219 DOI: 10.1093/rheumatology/kep107] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a devastating vascular complication of a number of CTDs. In patients with SSc, PAH has a dramatic impact on prognosis and survival and is the single most common cause of disease-related death.Yearly echocardiographic screening for PAH is recommended in patients with SSc. If suspected, confirmation of PAH diagnosis by right heart catheterization is necessary. Treatment goals for patients with PAH associated with SSc (PAH-SSc) aim to slow disease progression and improve quality of life. Some measures used to gauge the effect of treatment in patients with PAH-SSc remain to be fully validated; the 6-min walk distance, for example, is a simple and reproducible means of assessing exercise capacity, but there exists a need to understand what constitutes a clinically relevant change in this specific patient population. Currently, pharmacological intervention in PAH-SSc may target one or more of three pathophysiological pathways in PAH. The prostacyclin analogue epoprostenol has been shown to improve exercise capacity and haemodynamics in PAH-SSc patients and similar data are available from smaller studies on trepostinil and iloprost. The dual endothelin receptor antagonist bosentan has been shown to improve exercise capacity and haemodynamics in PAH-SSc, and similar data have been obtained in small numbers of patients treated with the endothelin receptor A antagonists sitaxsentan and ambrisentan. Impaired production of nitric oxide may be addressed by inhibiting phosphodiesterase type-5 with sildenafil or possibly tadalafil. Combinations of multiple targeted therapies may be beneficial to this patient population.
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Affiliation(s)
- V McLaughlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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250
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Taichman DB, McGoon MD, Harhay MO, Archer-Chicko C, Sager JS, Murugappan M, Chakinali MM, Palevsky HI, Gallop R. Wide variation in clinicians' assessment of New York Heart Association/World Health Organization functional class in patients with pulmonary arterial hypertension. Mayo Clin Proc 2009; 84:586-92. [PMID: 19567712 PMCID: PMC2704130 DOI: 10.1016/s0025-6196(11)60747-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess interrater reliability of the New York Heart Association/World Health Organization functional classification as applied by clinicians (defined as both physicians and nurses in this article) to patients with pulmonary arterial hypertension (PAH). PATIENTS AND METHODS Between March 16 and August 31, 2007, a survey that described 10 hypothetical patients was completed by physicians and nurses attending a conference on PAH. Results were subsequently validated with physicians and nurses who were contacted online through the Pulmonary Hypertension Association. Respondents were asked to assign each patient's functional class as they would normally in clinical practice. RESULTS The functional class evaluations were completed by 113 clinicians, 87 (77%) of whom had participated in PAH trials; 106 (94%) reported using functional class when determining therapy. Clinicians reported a broad range of factors they considered when evaluating functional class, and their assessments of functional class varied widely. The intraclass correlation coefficient was 0.58 for the initial patient survey and 0.62 for the online survey. At best, one patient was ranked as either class II (by 60 clinicians [53%]) or class III (by 53 [47%]). Clinicians' rankings spanned at least 3 functional classes for each of the other patients. Equally divergent rankings were observed among nurses and physicians. Cluster analysis identified clinicians' tendencies toward "higher" or "lower" functional class rankings. Of the 113 clinicians, 101 (89%) thought that the patients described resembled those seen in their practices. CONCLUSION Despite the wide use of the New York Heart Association/World Health Organization functional class in clinical care and as a research tool, interrater agreement may be inadequate. Efforts to promote a uniform approach to evaluating functional class might help to standardize PAH care and research.
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Affiliation(s)
- Darren B Taichman
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA 19104, USA.
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