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Ameri P, Mercurio V, Pollesello P, Anker MS, Backs J, Bayes-Genis A, Borlaug BA, Burkhoff D, Caravita S, Chan SY, de Man F, Giannakoulas G, González A, Guazzi M, Hassoun PM, Hemnes AR, Maack C, Madden B, Melenovsky V, Müller OJ, Papp Z, Pullamsetti SS, Rainer PP, Redfield MM, Rich S, Schiattarella GG, Skaara H, Stellos K, Tedford RJ, Thum T, Vachiery JL, van der Meer P, Van Linthout S, Pruszczyk P, Seferovic P, Coats AJS, Metra M, Rosano G, Rosenkranz S, Tocchetti CG. A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function. Eur J Heart Fail 2024; 26:707-729. [PMID: 38639017 PMCID: PMC11182487 DOI: 10.1002/ejhf.3236] [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: 07/26/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.
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Affiliation(s)
- Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiac, Thoracic, and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Piero Pollesello
- Content and Communication, Branded Products, Orion Pharma, Espoo, Finland
| | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin (Campus CBF), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Backs
- Institute of Experimental Cardiology, University Hospital Heidelberg, University of Heidelberg and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS Ospedale San Luca, Milan, Italy
| | - Stephen Y Chan
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Frances de Man
- PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aránzazu González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Marco Guazzi
- University of Milan, Milan, Italy
- Cardiology Division, San Paolo University Hospital, Milan, Italy
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cristoph Maack
- Comprehensive Heart Failure Center (CHFC) and Medical Clinic I, University Clinic Würzburg, Würzburg, Germany
| | | | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Oliver J Müller
- Department of Internal Medicine V, University Hospital Schleswig-Holstein, and German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Zoltan Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Soni Savai Pullamsetti
- Department of Internal Medicine and Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig University, Giessen, Germany
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- Department of Medicine, St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | | | - Stuart Rich
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gabriele G Schiattarella
- Max-Rubner Center (CMR), Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Hall Skaara
- Pulmonary Hypertension Association Europe, Vienna, Austria
| | - Kostantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Heidelberg University, Mannheim, Germany
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site, Heidelberg and Mannheim, Germany
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Jean Luc Vachiery
- Department of Cardiology, Hopital Universitaire de Bruxelles Erasme, Brussels, Belgium
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité, BIH Center for Regenerative Therapies, University of Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK, partner site Berlin), Berlin, Germany
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade University Medical Center, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
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Alkhatib D, Isa S, Pour-Ghaz I, Butt A, Al-Taweel O, Ugonabo I, Yedlapati N, Jefferies JL. Novel Device Therapies for Heart Failure. J Cardiovasc Dev Dis 2023; 10:jcdd10040165. [PMID: 37103044 PMCID: PMC10143883 DOI: 10.3390/jcdd10040165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 04/03/2023] [Indexed: 04/28/2023] Open
Abstract
Heart failure (HF) therapeutics have advanced significantly over the past few years [...].
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Affiliation(s)
- Deya Alkhatib
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Sakiru Isa
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Issa Pour-Ghaz
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Asra Butt
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Omar Al-Taweel
- Division of Cardiology, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89154, USA
| | - Ifeoma Ugonabo
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - Neeraja Yedlapati
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
| | - John Lynn Jefferies
- Division of Cardiovascular Disease, University of Tennessee Health Science Center, Memphis, TN 38103, USA
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Khattab E, Velidakis N, Gkougkoudi E, Kadoglou NP. Exercise-Induced Pulmonary Hypertension: A Valid Entity or Another Factor of Confusion? LIFE (BASEL, SWITZERLAND) 2023; 13:life13010128. [PMID: 36676077 PMCID: PMC9860538 DOI: 10.3390/life13010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/05/2023]
Abstract
Exercise-induced pulmonary hypertension EIPH has been defined as an increase in mean pulmonary arterial pressure (mPAP) during exercise in otherwise normal values at rest. EIPH reflects heart and/or lung dysfunction and may precede the development of manifest pulmonary hypertension (PH) in a proportion of patients. It is also associated with decreased life expectancy in patients with heart failure with reduced ejection fraction (HFrEF) or left ventricle (LV) valvular diseases. Diastolic dysfunction exacerbated during exercise relates to increased LV filling pressure and left atrial pressure (LAP). In this context backward, transmitted pressure alone or accompanied with backward blood flow promotes EIPH. The gold standard of EIPH assessment remains the right heart catheterization during exercise, which is an accurate but invasive method. Alternatively, non-invasive diagnostic modalities include exercise stress echocardiography (ESE) and cardiopulmonary exercise testing (CPET). Both diagnostic tests are performed under gradually increasing physical stress using treadmill and ergo-cycling protocols. Escalating workload during the exercise is analogous to the physiological response to real exercise. The results of the latter techniques show good correlation with invasive measurements, but they suffer from lack of validation and cut-off value determination. Although it is not officially recommended, there are accumulated data supporting the importance of EIPH diagnosis in the assessment of other mild/subclinical or probably fatal diseases in patients with latent PH or heart failure or LV valvular disease, respectively. Nevertheless, larger, prospective studies are required to ensure its role in clinical practice.
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Khedraki R, Abraham J, Jonsson O, Bhatt K, Omar HR, Bennett M, Bhimaraj A, Guha A, McCann P, Muse ED, Robinson M, Sauer AJ, Cheng A, Bagsic S, Fudim M, Heywood JT, Guglin M. Impact of exercise on pulmonary artery pressure in patients with heart failure using an ambulatory pulmonary artery pressure monitor. Front Cardiovasc Med 2023; 10:1077365. [PMID: 36937902 PMCID: PMC10019590 DOI: 10.3389/fcvm.2023.1077365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 02/07/2023] [Indexed: 03/06/2023] Open
Abstract
Background In this multicenter prospective study, we explored the relationship between pulmonary artery pressure (PAP) at rest and in response to a 6-min walk test (6MWT) in ambulatory patients with heart failure (HF) with an implantable PAP sensor (CardioMEMS, Abbott). Methods Between 5/2019 and 2/2021, HF patients with a CardioMEMS sensor were recruited from seven sites. PAP was recorded in the supine and seated position at rest and in the seated position immediately post-exercise. Results In our cohort of 66 patients, mean age was 70 ± 12 years, 67% male, left ventricular ejection fraction (LVEF) < 50% in 53%, mean 6MWT distance was 277 ± 95 meters. Resting seated PAPs were 31 ± 15 mmHg (systolic), 13 ± 8 mmHg (diastolic), and 20 ± 11 mmHg (mean). The pressures were lower in the seated rather than the supine position. After 6MWT, the pressures increased to PAP systolic 37 ± 19 mmHg (p < 0.0001), diastolic 15 ± 10 mmHg (p = 0.006), and mean 24 ± 13 mmHg (p < 0.0001). Patients with elevated PAP diastolic at rest (>15 mmHg) demonstrated a greater increase in post-exercise PAP. Conclusion The measurement of PAP with CardioMEMS is feasible immediately post-exercise. Despite being well-managed, patients had severely limited functional capacity. We observed a significant increase in PAP with ambulation which was greater in patients with higher baseline pressures.
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Affiliation(s)
- Rola Khedraki
- Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, La Jolla, CA, United States
| | - Jacob Abraham
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence Research Network, Portland, OR, United States
| | - Orvar Jonsson
- University of South Dakota Sanford Health, Sioux Falls, SD, United States
| | | | | | - Mosi Bennett
- Allina Health Minneapolis Heart Institute, Minneapolis, MN, United States
| | - Arvind Bhimaraj
- Houston Methodist Debakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Ashrith Guha
- Houston Methodist Debakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Patrick McCann
- PRISMA Health USC Medical Group, Greer, SC, United States
| | - Evan D. Muse
- Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, La Jolla, CA, United States
- Scripps Research Translational Institute, La Jolla, CA, United States
| | - Monique Robinson
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Andrew J. Sauer
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO, United States
| | - Andrew Cheng
- Department of Cardiology, Ascension Medical Group, Austin, TX, United States
| | - Samantha Bagsic
- Scripps Research Translational Institute, La Jolla, CA, United States
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, United States
- Duke Clinical Research Institute, Durham, NC, United States
| | - J. Thomas Heywood
- Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, La Jolla, CA, United States
| | - Maya Guglin
- Indiana University School of Medicine, Indianapolis, IN, United States
- *Correspondence: Maya Guglin,
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Lunardi M, Wu S, Serruys PW, Onuma Y, Soliman O, Wijns W, Mullens W, Sharif F. Acute and chronic exercise training in patients with Class II pulmonary hypertension: effects on haemodynamics and symptoms. ESC Heart Fail 2022; 9:791-799. [PMID: 35132779 PMCID: PMC8934934 DOI: 10.1002/ehf2.13819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 12/10/2021] [Accepted: 01/17/2022] [Indexed: 11/24/2022] Open
Abstract
More than half of heart failure (HF) patients have concomitant pulmonary hypertension, impacting symptoms and prognosis. The role of exercise in this category of patients is still unclear, probably because of the lack of a clear relationship between exercise and acute and chronic pulmonary artery pressure variations and related changes in symptoms. The limited evidence on this topic is contradictory and hardly comparable due to use of different exercise programmes and pulmonary artery pressure assessment techniques. This is further compounded by different functional and structural classes of HF making definite assessments and interpretations of exercise effect on outcomes difficult. Exercise training programmes were proven beneficial in HF patients; however, the lack of data about their pulmonary haemodynamic effects prevents clear indications on the best exercise types for patients presenting secondary pulmonary hypertension and different HF categories. Indeed, some data suggest that not all HF patients have similar responses to training, leading to either beneficial or detrimental effects, depending on the HF type. Future studies, involving modern technologies such as continuous pulmonary artery pressure monitoring implantable devices, may clarify the current gaps in this field, aiming at patient‐tailored exercise training rehabilitation programmes, in order to improve clinical outcomes, quality of life, and hopefully prognosis.
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Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Sijing Wu
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,Department of Cardiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Patrick W Serruys
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,International Centre for Circulatory Health, NHLI, Imperial College, London, UK
| | - Yoshinobu Onuma
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Osama Soliman
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland
| | - William Wijns
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland.,The Lambe Institute for Translational Medicine and CURAM, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Wilfried Mullens
- Department of Cardiovascular Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Faisal Sharif
- Department of Cardiology, Saolta Group, Galway University Hospital, Health Service Executive and National University of Ireland Galway (NUIG), Galway, Ireland
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Fudim M, Abraham WT, von Bardeleben RS, Lindenfeld J, Ponikowski PP, Salah HM, Khan MS, Sievert H, Stone GW, Anker SD, Butler J. Device Therapy in Chronic Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:931-956. [PMID: 34446165 PMCID: PMC9941752 DOI: 10.1016/j.jacc.2021.06.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
The regulatory landscape for device-based heart failure (HF) therapies has seen a major shift in the last 7 years. In 2013, the U.S. Food and Drug Administration released guidance for early feasibility and first-in-human studies, thereby encouraging device innovation, and in 2016 the U.S. Congress authorized the Breakthrough Devices Program to expedite access for Americans to innovative devices indicated for diagnosis and treatment of serious illnesses, such as HF. Since December 2016, there has been an increase in the number of HF devices for which manufacturers are seeking approval through the breakthrough designation pathway. This has led to a rapid uptake in the development and evaluation of device-based HF therapies. This article reviews the current and future landscape of device therapies for chronic HF and associated comorbidities and the regulatory environment that is driving current and future innovation.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - William T. Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Ralph Stephan von Bardeleben
- Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Piotr P. Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland,Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Husam M. Salah
- Department of Medicine, University of Arkansas for Medical Sciences, AR, USA
| | - Muhammad Shahzeb Khan
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, and the Cardiovascular Research Foundation, New York, NY, USA
| | - Stefan D. Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA.
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Stiles TW, Morfin Rodriguez AE, Mohiuddin HS, Lee H, Dalal FA, Fuertes WW, Adams TH, Stewart RH, Quick CM. Algebraic formulas characterizing an alternative to Guyton's graphical analysis relevant for heart failure. Am J Physiol Regul Integr Comp Physiol 2021; 320:R851-R870. [PMID: 33596744 DOI: 10.1152/ajpregu.00260.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although Guyton's graphical analysis of cardiac output-venous return has become a ubiquitous tool for explaining how circulatory equilibrium emerges from heart-vascular interactions, this classical model relies on a formula for venous return that contains unphysiological assumptions. Furthermore, Guyton's graphical analysis does not predict pulmonary venous pressure, which is a critical variable for evaluating heart failure patients' risk of pulmonary edema. Therefore, the purpose of the present work was to use a minimal closed-loop mathematical model to develop an alternative to Guyton's analysis. Limitations inherent in Guyton's model were addressed by 1) partitioning the cardiovascular system differently to isolate left ventricular function and lump all blood volumes together, 2) linearizing end-diastolic pressure-volume relationships to obtain algebraic solutions, and 3) treating arterial pressures as constants. This approach yielded three advances. First, variables related to morbidities associated with left ventricular failure were predicted. Second, an algebraic formula predicting left ventricular function was derived in terms of ventricular properties. Third, an algebraic formula predicting flow through the portion of the system isolated from the left ventricle was derived in terms of mechanical properties without neglecting redistribution of blood between systemic and pulmonary circulations. Although complexities were neglected, approximations necessary to obtain algebraic formulas resulted in minimal error, and predicted variables were consistent with reported values.
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Affiliation(s)
- Thomas W Stiles
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | | | - Hanifa S Mohiuddin
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Hyunjin Lee
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Fazal A Dalal
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Wesley W Fuertes
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Thaddeus H Adams
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Randolph H Stewart
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
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8
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Xu D, Zhang H, Cheng H, Xu T, Sun W, Sheng Y, Yang R, Xu D, Zhou F, Zhou Y, Xu F, Zhu H, Cheang I, Ding Q, Chen Y, Zhao P, Kong X, Li X, Zhang H. Pulmonary hypertension due to left heart disease with pulmonary arterial wedge pressure ≤15 mm Hg. Herz 2020; 46:209-214. [PMID: 32990814 DOI: 10.1007/s00059-020-04983-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/14/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pulmonary hypertension due to left heart disease (PH-LHD) is the most prevalent type of pulmonary hypertension (PH). The hemodynamic diagnostic standard of pulmonary arterial wedge pressure (PAWP) >15 mm Hg that is traditionally recommended by guidelines is being challenged. METHODS To address this problem, we analyzed the data of 154 patients with PH-LHD admitted to our center from April 2013 to March 2018. Pharmacological or nonpharmacological treatment of underlying left heart disease was offered to all 154 patients. RESULTS In total, there were 24 patients (15.6%) with PAWP ≤15 mm Hg. Comparison of echocardiography and right heart catheterization parameters between the two groups (PAWP >15 mm Hg and PAWP ≤15 mm Hg) showed that the group with PAWP ≤15 mm Hg had smaller left ventricular diameter, higher cardiac output, lower pressure and higher oxygen saturation in the pulmonary artery, right atrium, right ventricle, and superior vena cava. No significant difference was found regarding dilated cardiomyopathy, diabetes mellitus, hypertension, atrial fibrillation, and left heart valvular disease, but a significant difference was found for coronary heart disease (higher morbidity in group with PAWP ≤15 mm Hg) between the two groups. CONCLUSION We found that 15.6% of the patients with PH-LHD under pharmacological or nonpharmacological treatment had PAWP ≤15 mm Hg. These results suggest that the diagnostic criterion of PAWP and the characteristics for this group of patients should be further investigated.
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Affiliation(s)
- Dongxu Xu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China.,Department of Cardiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Hao Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Huiling Cheng
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Tianbao Xu
- Department of Cardiology, The People's Hospital of Kizilsu Kirghiz Autonomous Prefecture, Xinjiang, China
| | - Wei Sun
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Yanhui Sheng
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Rong Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Dongjie Xu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Fang Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Yanli Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Fang Xu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Hongyan Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - IokFai Cheang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Qiang Ding
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China.,Department of Cardiology, The People's Hospital of Kizilsu Kirghiz Autonomous Prefecture, Xinjiang, China
| | - Yan Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China.,Department of Cardiology, The People's Hospital of Kizilsu Kirghiz Autonomous Prefecture, Xinjiang, China
| | - Pei Zhao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China.,Department of Cardiology, The People's Hospital of Kizilsu Kirghiz Autonomous Prefecture, Xinjiang, China
| | - Xiangqing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Xinli Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China
| | - Haifeng Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, 210029, Nanjing, China. .,Department of Cardiology, The People's Hospital of Kizilsu Kirghiz Autonomous Prefecture, Xinjiang, China.
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9
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Jain CC, Warnes CA, Egbe AC, Cetta F, DuBrock HM, Connolly HM, Miranda WR. Hemodynamics in Adults With the Shone Complex. Am J Cardiol 2020; 130:137-142. [PMID: 32703525 DOI: 10.1016/j.amjcard.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/31/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022]
Abstract
Patients with Shone complex (SC) have multiple left-sided obstructive lesions and thus are at risk for left ventricular (LV) remodeling, LV diastolic dysfunction and pulmonary hypertension. Yet, to date, there has been no description of hemodynamics in adults with SC. Retrospective chart review of 25 patients with SC who underwent cardiac catheterization at Mayo Clinic, MN between 2002 and 2019 was performed. SC was defined as multiple left-sided obstructive lesions in the presence of an anatomically abnormal mitral valve. Median age was 32 years (22.5, 42) and 15 patients (60%) were female. The majority of patients (84%) had history of coarctation of the aorta, 10 (40%) had subaortic stenosis, 11 (44%) had prior aortic valve replacement, and 10 (40%) had prior mitral valve replacement. Structural disease at the time of catheterization which warranted intervention within the next year was present in 13 patients (52%). The mean LV end-diastolic pressure was 21.3 ± 9.0 mm Hg (>15 mm Hg in 71%), pulmonary artery peak systolic pressure was 55.4 ± 13.4 mm Hg, and the pulmonary artery mean pressure was 37.0 ± 9.4 mm Hg (>20 mm Hg in 96%). During a mean follow-up of 8.3 ± 4.4 years, there were 7 deaths (28%) and 3 additional patients (12%) underwent cardiac transplantation. In conclusion, adults with SC who underwent catheterization showed significant left-sided heart and pulmonary vascular remodeling. Elevated LV end-diastolic pressure and pulmonary artery pressures were highly prevalent. There were high mortality and cardiac transplant rates in our cohort.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota
| | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota
| | | | - Frank Cetta
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota; Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Minnesota
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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10
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Al-Omary MS, Sugito S, Boyle AJ, Sverdlov AL, Collins NJ. Pulmonary Hypertension Due to Left Heart Disease. Hypertension 2020; 75:1397-1408. [DOI: 10.1161/hypertensionaha.119.14330] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is the most common type of PH and is defined as mean pulmonary artery systolic pressure of >20 mm Hg and pulmonary capillary wedge pressure >15 mm Hg during right heart catheterization. LHD may lead to elevated left atrial pressure alone, which in the absence of intrinsic pulmonary vascular disease will result in PH without changes in pulmonary vascular resistance. Persistent elevation in left atrial pressure may, however, also be associated with subsequent pulmonary vascular remodeling, vasoconstriction, and an increase in pulmonary vascular resistance. Hence, there are 2 subgroups of PH due to LHD, isolated postcapillary PH and combined post- and precapillary PH, with these groups have differing clinical implications. Differentiation of pulmonary arterial hypertension and PH due to LHD is critical to guide management planning; however, this may be challenging. Older patients, patients with metabolic syndrome, and patients with imaging and clinical features consistent with left ventricular dysfunction are suggestive of LHD etiology rather than pulmonary arterial hypertension. Hemodynamic measures such as diastolic pressure gradient, transpulmonary gradient, and pulmonary vascular resistance may assist to differentiate pre- from postcapillary PH and offer prognostic insights. However, these are influenced by fluid status and heart failure treatment. Pulmonary arterial hypertension therapies have been trialed in the treatment with concerning results reflecting disease heterogeneity, variation in inclusion criteria, and mixed end point criteria. The aim of this review is to provide an updated definition, discuss possible pathophysiology, clinical aspects, and the available treatment options for PH due to LHD.
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Affiliation(s)
- Mohammed S. Al-Omary
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Stuart Sugito
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
| | - Andrew J. Boyle
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Aaron L. Sverdlov
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
| | - Nicholas J. Collins
- From the Cardiovascular Department, John Hunter Hospital, Newcastle, Australia (M.S.A., S.S., A.J.B., A.L.S., N.J.C.)
- School of Medicine and Public Health, University of Newcastle, Australia (M.S.A., A.J.B., A.L.S., N.J.C.)
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11
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LA Mechanics in Decompensated Heart Failure. JACC Cardiovasc Imaging 2020; 13:1107-1115. [DOI: 10.1016/j.jcmg.2019.12.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/25/2019] [Accepted: 12/05/2019] [Indexed: 11/21/2022]
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12
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Echocardiographic Pulmonary to Left Atrial Ratio (ePLAR): A Comparison Study between Ironman Athletes, Age Matched Controls and A General Community Cohort. J Clin Med 2019; 8:jcm8101756. [PMID: 31652633 PMCID: PMC6832979 DOI: 10.3390/jcm8101756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 01/10/2023] Open
Abstract
Background: During exercise there is a proportionally lower rise in systemic and pulmonary pressures compared to cardiac output due to reduced vascular resistance. Invasive exercise data suggest that systemic vascular resistance reduces more than pulmonary vascular resistance. The aim of this study was the non-invasive assessment of exercise hemodynamics in ironman athletes, compared with an age matched control group and a larger general community cohort. Methods: 20 ironman athletes (40 ± 11 years, 17 male) were compared with 20 age matched non-athlete controls (43 ± 7 years, 10 male) and a general community cohort of 230 non-athletes individuals (66 ± 11 years, 155 male), at rest and after maximal-symptom limited treadmill exercise stress echocardiography. Left heart parameters (mitral E-wave, e’-wave and E/e’) and right heart parameters (tricuspid regurgitation maximum velocity and right ventricular systolic pressure), were used to calculate the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) value of the three groups. Results: Athletes exercised for 12.2 ± 0.53 min, age matched controls for 10.1 ± 2.8 min and general community cohort for 8.3 ± 2.6 min. Mitral E/e’ rose slightly for athletes (0.9 ± 1.8), age matched controls (0.6 ± 3.0) and non-athletes (0.4 ± 3.2). Right ventricular systolic pressure increased significantly more in athletes than in both non-athlete cohorts (35.6 ± 17 mmHg vs. 20.4 ± 10.8 mmHg and 18 ± 9.6 mmHg). The marker of trans-pulmonary gradient, ePLAR, rose significantly more in athletes than in both non-athlete groups (0.15 ± 0.1 m/s vs. 0.07 ± 0.1 m/s). Conclusions: Pulmonary pressures increased proportionally four-fold compared with systemic pressures in ironman athletes. This increase in pulmonary vascular resistance corresponded with a two-fold increase in ePLAR. These changes were exaggerated compared with both non-ironman cohorts. Such changes have been previously suggested to lead to right ventricle dysfunction, arrhythmias and sudden cardiac death.
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13
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Berthelot E, Bailly MT, Hatimi SE, Robard I, Rezgui H, Bouchachi A, Montani D, Sitbon O, Chemla D, Assayag P. Pulmonary hypertension due to left heart disease. Arch Cardiovasc Dis 2017; 110:420-431. [PMID: 28411107 DOI: 10.1016/j.acvd.2017.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 01/24/2017] [Indexed: 01/03/2023]
Abstract
Pulmonary hypertension due to left heart disease, also known as group 2 pulmonary hypertension according to the European Society of Cardiology/European Respiratory Society classification, is the most common cause of pulmonary hypertension. In patients with left heart disease, the development of pulmonary hypertension favours right heart dysfunction, which has a major impact on disease severity and outcome. Over the past few years, this condition has been considered more frequently. However, epidemiological studies of group 2 pulmonary hypertension are less exhaustive than studies of other causes of pulmonary hypertension. In group 2 patients, pulmonary hypertension may be caused by an isolated increase in left-sided filling pressures or by a combination of this condition with increased pulmonary vascular resistance, with an abnormally high pressure gradient between arteries and pulmonary veins. A better understanding of the conditions underlying pulmonary hypertension is of key importance to establish a comprehensive diagnosis, leading to an adapted treatment to reduce heart failure morbidity and mortality. In this review, epidemiology, mechanisms and diagnostic approaches are reviewed; then, treatment options and future approaches are considered.
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Affiliation(s)
| | - Minh Tam Bailly
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Safwane El Hatimi
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ingrid Robard
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Hatem Rezgui
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Amir Bouchachi
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Sitbon
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Denis Chemla
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France; AP-HP, Service de Physiologie, Unité INSERM U_999, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Patrick Assayag
- AP-HP, Service de Cardiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
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14
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Metra M, Carubelli V, Ravera A, Stewart Coats AJ. Heart failure 2016: still more questions than answers. Int J Cardiol 2016; 227:766-777. [PMID: 27838123 DOI: 10.1016/j.ijcard.2016.10.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/23/2016] [Accepted: 10/23/2016] [Indexed: 12/21/2022]
Abstract
Heart failure has reached epidemic proportions given the ageing of populations and is associated with high mortality and re-hospitalization rates. This article reviews and summarizes recent advances in the diagnosis, assessment and treatment of the patients with heart failure. Data are discussed based also on the most recent guidelines indications. Open issues and unmet needs are highlighted.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Valentina Carubelli
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Alice Ravera
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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15
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Sodium Nitroprusside in Patients With Mixed Pulmonary Hypertension and Left Heart Disease: Hemodynamic Predictors of Response and Prognostic Implications. J Card Fail 2016; 22:117-24. [DOI: 10.1016/j.cardfail.2015.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 10/25/2015] [Accepted: 10/27/2015] [Indexed: 11/18/2022]
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16
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Verbrugge FH, Dupont M, Finucan M, Gabi A, Hawwa N, Mullens W, Taylor DO, Young JB, Starling RC, Tang WHW. Response and tolerance to oral vasodilator up-titration after intravenous vasodilator therapy in advanced decompensated heart failure. Eur J Heart Fail 2015. [PMID: 26213182 DOI: 10.1002/ejhf.324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
AIMS The aim of this study was to assess the haemodynamic response and tolerance to aggressive oral hydralazine/isosorbide dinitrate (HYD/ISDN) up-titration after intravenous vasodilator therapy in advanced decompensated heart failure (ADHF). METHODS AND RESULTS Medical records of 147 consecutive ADHF patients who underwent placement of a pulmonary artery catheter and received intravenous vasodilator therapy were reviewed. Intravenous sodium nitroprusside and sodium nitroglycerin as first-line agent for those with preserved blood pressures were utilized in 143 and 32 patients, respectively. Sixty-one percent of patients were converted to oral HYD/ISDN combination therapy through a standardized conversion protocol. These patients had a significantly higher admission mean pulmonary arterial wedge pressure compared with patients not converted (28 ± 7 vs. 25 ± 8 mmHg, respectively; P-value 0.024). Beneficial haemodynamic response to decongestive therapy, defined as low cardiac filling pressures and cardiac index ≥2.20 L/min/m(2) without emergent hypotension, was achieved in 32% and 29% of patients who did or did not receive oral HYD/ISDN, respectively (P-value 0.762). HYD/ISDN dosing was progressively and consistently decreased up to the moment of hospital discharge and during outpatient follow-up, primarily due to incident hypotension. CONCLUSION The use of a standardized haemodynamically guided up-titration protocol for conversion from intravenous to oral vasodilators may warrant subsequent dose reductions upon stabilization.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Michael Finucan
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Alaa Gabi
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Nael Hawwa
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - David O Taylor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - James B Young
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH, USA
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17
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Metra M. March 2015 at a glance. Eur J Heart Fail 2015; 17:235-6. [DOI: 10.1002/ejhf.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health; University of Brescia; Brescia Italy
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18
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Dickstein K. Increased pulmonary vascular resistance, right ventricular dysfunction, and reversible pulmonary vasoconstriction in type 2 pulmonary hypertension: who has it and are we missing a potential therapeutic target in patients with heart failure? Eur J Heart Fail 2015; 17:237-8. [DOI: 10.1002/ejhf.248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/16/2015] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kenneth Dickstein
- Cardiology Division; University of Bergen, Stavanger University Hospital; Norway
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