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Zeder K, Brittain E, Kovacs G, Maron BA. The Management of Mild Pulmonary Hypertension in Clinical Practice. Ann Am Thorac Soc 2024; 21:1115-1123. [PMID: 38747696 PMCID: PMC11298986 DOI: 10.1513/annalsats.202312-1079fr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/15/2024] [Indexed: 08/02/2024] Open
Abstract
The definition of pulmonary hypertension (PH) has been revised recently, with the mean pulmonary artery pressure (mPAP) threshold (assessed by right heart catheterization) reduced from ⩾25 mm Hg to >20 mm Hg. This change reflects the mPAP upper limit of normal and a lower limit that is independently associated with adverse outcomes. To improve the specificity of diagnosing pathogenic increases in mPAP, however, a diagnosis of precapillary PH now also includes pulmonary vascular resistance >2.0 Wood units (WU) (lowered from >3.0 WU). These changes are positioned to capture approximately 55% more patients with PH. Because all clinical trials showing a benefit of pulmonary vasodilator therapy in precapillary PH used the classical hemodynamic definition, the approach to the diagnosis and management of patients with mild PH (i.e., mPAP 21-24 mm Hg and pulmonary vascular resistance 2-3 WU) requires particular consideration. Here, we use a question/answer format to discuss key areas in the management of mild PH, including practical information tailored to clinicians without training in PH.
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Affiliation(s)
- Katarina Zeder
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
| | - Evan Brittain
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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DuBrock HM, Wagner TE, Carlson K, Carpenter CL, Awasthi S, Attia ZI, Frantz RP, Friedman PA, Kapa S, Annis J, Brittain EL, Hemnes AR, Asirvatham SJ, Babu M, Prasad A, Yoo U, Barve R, Selej M, Agron P, Kogan E, Quinn D, Dunnmon P, Khan N, Soundararajan V. An electrocardiogram-based AI algorithm for early detection of pulmonary hypertension. Eur Respir J 2024; 64:2400192. [PMID: 38936966 PMCID: PMC11269769 DOI: 10.1183/13993003.00192-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/19/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Early diagnosis of pulmonary hypertension (PH) is critical for effective treatment and management. We aimed to develop and externally validate an artificial intelligence algorithm that could serve as a PH screening tool, based on analysis of a standard 12-lead ECG. METHODS The PH Early Detection Algorithm (PH-EDA) is a convolutional neural network developed using retrospective ECG voltage-time data, with patients classified as "PH-likely" or "PH-unlikely" (controls) based on right heart catheterisation or echocardiography. In total, 39 823 PH-likely patients and 219 404 control patients from Mayo Clinic were randomly split into training (48%), validation (12%) and test (40%) sets. ECGs taken within 1 month of PH diagnosis (diagnostic dataset) were used to train the PH-EDA at Mayo Clinic. Performance was tested on diagnostic ECGs within the test sets from Mayo Clinic (n=16 175/87 998 PH-likely/controls) and Vanderbilt University Medical Center (VUMC; n=6045/24 256 PH-likely/controls). In addition, performance was tested on ECGs taken 6-18 months (pre-emptive dataset), and up to 5 years prior to a PH diagnosis at both sites. RESULTS Performance testing yielded an area under the receiver operating characteristic curve (AUC) of 0.92 and 0.88 in the diagnostic test sets at Mayo Clinic and VUMC, respectively, and 0.86 and 0.81, respectively, in the pre-emptive test sets. The AUC remained a minimum of 0.79 at Mayo Clinic and 0.73 at VUMC up to 5 years before diagnosis. CONCLUSION The PH-EDA can detect PH at diagnosis and 6-18 months prior, demonstrating the potential to accelerate diagnosis and management of this debilitating disease.
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Affiliation(s)
- Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Co-first authors
| | - Tyler E Wagner
- nference, Cambridge, MA, USA
- Anumana, Cambridge, MA, USA
- Co-first authors
| | | | | | - Samir Awasthi
- nference, Cambridge, MA, USA
- Anumana, Cambridge, MA, USA
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey Annis
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Evan L Brittain
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Melwin Babu
- Anumana, Cambridge, MA, USA
- nference Labs, Bangalore, India
| | - Ashim Prasad
- Anumana, Cambridge, MA, USA
- nference Labs, Bangalore, India
| | | | - Rakesh Barve
- Anumana, Cambridge, MA, USA
- nference Labs, Bangalore, India
| | - Mona Selej
- Janssen Research and Development, LLC, a Johnson and Johnson company, Raritan, NJ, USA
| | - Peter Agron
- Janssen Research and Development, LLC, a Johnson and Johnson company, Raritan, NJ, USA
| | - Emily Kogan
- Janssen Research and Development, LLC, a Johnson and Johnson company, Raritan, NJ, USA
| | - Deborah Quinn
- Janssen Research and Development, LLC, a Johnson and Johnson company, Raritan, NJ, USA
| | - Preston Dunnmon
- Janssen Research and Development, LLC, a Johnson and Johnson company, Raritan, NJ, USA
| | - Najat Khan
- Janssen Research and Development, LLC, a Johnson and Johnson company, Raritan, NJ, USA
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Sun H, Du Z, Zhang X, Gao S, Ji Z, Luo G, Pan S. Neutrophil extracellular traps promote proliferation of pulmonary smooth muscle cells mediated by CCDC25 in pulmonary arterial hypertension. Respir Res 2024; 25:183. [PMID: 38664728 PMCID: PMC11046914 DOI: 10.1186/s12931-024-02813-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Previous studies have indicated that neutrophil extracellular traps (NETs) play a pivotal role in pathogenesis of pulmonary arterial hypertension (PAH). However, the specific mechanism underlying the impact of NETs on pulmonary artery smooth muscle cells (PASMCs) has not been determined. The objective of this study was to elucidate underlying mechanisms through which NETs contribute to progression of PAH. METHODS Bioinformatics analysis was employed in this study to screen for potential molecules and mechanisms associated with occurrence and development of PAH. These findings were subsequently validated in human samples, coiled-coil domain containing 25 (CCDC25) knockdown PASMCs, as well as monocrotaline-induced PAH rat model. RESULTS NETs promoted proliferation of PASMCs, thereby facilitating pathogenesis of PAH. This phenomenon was mediated by the activation of transmembrane receptor CCDC25 on PASMCs, which subsequently activated ILK/β-parvin/RAC1 pathway. Consequently, cytoskeletal remodeling and phenotypic transformation occur in PASMCs. Furthermore, the level of NETs could serve as an indicator of PAH severity and as potential therapeutic target for alleviating PAH. CONCLUSION This study elucidated the involvement of NETs in pathogenesis of PAH through their influence on the function of PASMCs, thereby highlighting their potential as promising targets for the evaluation and treatment of PAH.
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Affiliation(s)
- Hongxiao Sun
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Zhanhui Du
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Xu Zhang
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Shuai Gao
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Zhixian Ji
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Gang Luo
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Silin Pan
- Heart Center, Women and Children's Hospital, Qingdao University, Qingdao, China.
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Jose A, Rahman N, Opotowsky AR, Glorioso TJ, Waldo SW, Zeder K, Seto A, Elwing JM, McCormack FX, Maron BA. Association of Cardiopulmonary Hemodynamics and Mortality in Veterans With Liver Cirrhosis: A Retrospective Cohort Study. J Am Heart Assoc 2024; 13:e033847. [PMID: 38567662 PMCID: PMC11262483 DOI: 10.1161/jaha.123.033847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Portopulmonary hypertension (PoPH), associated with increased mortality, can limit treatment options for liver diseases. Data on the continuum of clinical risk related to cardiopulmonary hemodynamics in PoPH are lacking. METHODS AND RESULTS As part of the United States national Veterans Affairs Clinical Assessment, Reporting, and Tracking database, we performed a retrospective cohort study of adults with cirrhosis undergoing right heart catheterization between October 1, 2017, and September 30, 2022. Pulmonary hypertension (mean pulmonary arterial pressure [mPAP] >20 mm Hg without PoPH) and PoPH (mPAP >20 mm Hg+pulmonary artery wedge pressure ≤15 mm Hg+pulmonary vascular resistance ≥3 WU) were defined by right heart catheterization hemodynamics. Multivariable Cox proportional hazards using natural splines for hemodynamic variables were used to evaluate the association between cardiopulmonary hemodynamics and mortality following right heart catheterization. A total of 4409 patients were included in the final analysis, predominantly men (96.3%), with a mean age of 68.5 years. Pulmonary hypertension and PoPH were observed in 71.6% and 10.2% of the cohort, respectively. Compared with a reference cardiac index of 2.5 L/min per m2, the hazard for mortality increased progressively with decreasing cardiac index, even after adjustment for mPAP and pulmonary vascular resistance. The minority of patients with PoPH (N=65, 14.5%) were prescribed pulmonary vasodilator therapy. CONCLUSIONS These data suggest that pulmonary hypertension and PoPH are prevalent in veterans with chronic liver disease, but low use of targeted PoPH therapy persists. Cardiac function discriminated mortality risk across a wide range of mPAP and pulmonary vascular resistance values and may diagnose and clarify prognosis in this patient population.
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Affiliation(s)
- Arun Jose
- Veterans Affairs Cincinnati Healthcare SystemCincinnatiOH
- University of CincinnatiOH
| | - Natalia Rahman
- Rocky Mountain Regional VA Medical CenterAuroraCO
- Denver Research InstituteAuroraCO
| | - Alexander R. Opotowsky
- Heart Institute, Cincinnati Children’s Hospital Medical Center, University of CincinnatiOH
| | - Thomas J. Glorioso
- CART Program, Office of Quality and Patient Safety, Veterans Health AdministrationWashingtonDC
| | - Stephen W. Waldo
- Rocky Mountain Regional VA Medical CenterAuroraCO
- CART Program, Office of Quality and Patient Safety, Veterans Health AdministrationWashingtonDC
- University of Colorado School of MedicineAuroraCO
| | - Katarina Zeder
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMA
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMD
- The University of Maryland‐Institute for Health ComputingBethesdaMD
- Ludwig Boltzmann Institute for Lung Vascular Research, Medical University of GrazAustria
| | - Arnold Seto
- Veteran’s Affairs Long Beach Healthcare SystemLong BeachCA
| | | | - Francis X. McCormack
- Veterans Affairs Cincinnati Healthcare SystemCincinnatiOH
- University of CincinnatiOH
| | - Bradley A. Maron
- Veterans Affairs Boston Healthcare SystemBostonMA
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMA
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMD
- The University of Maryland‐Institute for Health ComputingBethesdaMD
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Johnson S, Sommer N, Cox-Flaherty K, Weissmann N, Ventetuolo CE, Maron BA. Pulmonary Hypertension: A Contemporary Review. Am J Respir Crit Care Med 2023; 208:528-548. [PMID: 37450768 PMCID: PMC10492255 DOI: 10.1164/rccm.202302-0327so] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Abstract
Major advances in pulmonary arterial hypertension, pulmonary hypertension (PH) associated with lung disease, and chronic thromboembolic PH cast new light on the pathogenetic mechanisms, epidemiology, diagnostic approach, and therapeutic armamentarium for pulmonary vascular disease. Here, we summarize key basic, translational, and clinical PH reports, emphasizing findings that build on current state-of-the-art research. This review includes cutting-edge progress in translational pulmonary vascular biology, with a guide to the diagnosis of patients in clinical practice, incorporating recent PH definition revisions that continue emphasis on early detection of disease. PH management is reviewed including an overview of the evolving considerations for the approach to treatment of PH in patients with cardiopulmonary comorbidities, as well as a discussion of the groundbreaking sotatercept data for the treatment of pulmonary arterial hypertension.
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Affiliation(s)
- Shelsey Johnson
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Boston University School of Medicine, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine and
| | - Natascha Sommer
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | | | - Norbert Weissmann
- Excellence Cluster Cardiopulmonary Institute, Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research, Justus Liebig University, Giessen, Germany
| | - Corey E. Ventetuolo
- Department of Medicine and
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
- Department of Cardiology and Department of Pulmonary, Allergy, Sleep, and Critical Care Medicine, VA Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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