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Hojda SE, Chis IC, Clichici S. Biomarkers in Pulmonary Arterial Hypertension. Diagnostics (Basel) 2022; 12:diagnostics12123033. [PMID: 36553040 PMCID: PMC9776459 DOI: 10.3390/diagnostics12123033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe medical condition characterized by elevated pulmonary vascular resistance (PVR), right ventricular (RV) failure, and death in the absence of appropriate treatment. The progression and prognosis are strictly related to the etiology, biochemical parameters, and treatment response. The gold-standard test remains right-sided heart catheterization, but dynamic monitoring of systolic pressure in the pulmonary artery is performed using echocardiography. However, simple and easily accessible non-invasive assays are also required in order to monitor this pathology. In addition, research in this area is in continuous development. In recent years, more and more biomarkers have been studied and included in clinical guidelines. These biomarkers can be categorized based on their associations with inflammation, endothelial cell dysfunction, cardiac fibrosis, oxidative stress, and metabolic disorders. Moreover, biomarkers can be easily detected in blood and urine and correlated with disease severity, playing an important role in diagnosis, prognosis, and disease progression.
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2
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Zhao C, Guo Y, Wang Y, Wang L, Yu L, Liang Y, Zhai Z, Tang L. The efficacy and safety of Sacubitril/Valsartan on pulmonary hypertension in hemodialysis patients. Front Med (Lausanne) 2022; 9:1055330. [PMID: 36523777 PMCID: PMC9745023 DOI: 10.3389/fmed.2022.1055330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/09/2022] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common complication of end-stage renal disease which is associated with adverse outcomes including all-cause mortality and cardiovascular events. Recent studies have demonstrated that Sacubitril/Valsartan (Sac/Val) as an enkephalinase inhibitor and angiotensin II receptor blocker could reduce pulmonary artery systolic pressure (PASP) and improve the prognosis of patients with heart failure. However, whether Sac/Val is effective in hemodialysis (HD) patients with PH is essentially unknown. In this retrospective study, we aimed to evaluate the efficacy and safety of Sac/Val in the treatment of PH in HD patients. METHODS A total of 122 HD patients with PH were divided into Sac/Val group (n = 71) and ARBs group (n = 51) based on the treatment regimen. The PASP, other cardiac parameters measured by echocardiography, and cardiac biomarkers including N-terminal fragment of BNP (NT-proBNP) and cardiac troponin I (cTnI) were observed at baseline and 3 months after treatment. RESULTS There were no significant differences in the baseline characteristics between the two groups. PASP decreased significantly from 45(38, 54) to 28(21, 40) mmHg in Sac/Val group (p < 0.001). PASP reduced from 41(37, 51) to 34(27, 44) mmHg in ARBs group (p < 0.001), and the decrease was more pronounced in the Sac/Val group (p < 0.001). In addition, improvements in the right atrial diameter (RAD), left ventricular diameter (LVD), left ventricular posterior wall thickness (LVPWT), left atrial diameter (LAD), pulmonary artery diameter (PAD), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), and fractional shortening (FS) were found in Sac/Val group (ps < 0.05). After 3 months, LVD, LAD, LVEDV, LVESV, LVEF, SV, and PASP were significantly improved in Sac/Val group compared with ARBs group (ps <0.05). Significant reduction in NT-proBNP [35,000 (15,000, 70,000) pg/ml vs. 7,042 (3,126, 29,060) pg/ml, p < 0.001] and cTnI [0.056(0.031, 0.085) ng/ml vs. 0.036 (0.012, 0.056) ng/ml, p < 0.001) were observed in Sac/Val group. No significant differences were observed in adverse events between the two groups (ps > 0.05). CONCLUSION Sac/Val seems to be an efficacious regimen in PH with favorable safety and has huge prospects for treating PH in HD patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Lin Tang
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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3
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Saviñon-Flores AI, Saviñon-Flores F, Trejo G, Méndez E, Ţălu Ş, González-Fuentes MA, Méndez-Albores A. A review of cardiac troponin I detection by surface enhanced Raman spectroscopy: Under the spotlight of point-of-care testing. Front Chem 2022; 10:1017305. [PMID: 36311415 PMCID: PMC9608872 DOI: 10.3389/fchem.2022.1017305] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/29/2022] [Indexed: 11/29/2022] Open
Abstract
Cardiac troponin I (cTnI) is a biomarker widely related to acute myocardial infarction (AMI), one of the leading causes of death around the world. Point-of-care testing (POCT) of cTnI not only demands a short turnaround time for its detection but the highest accuracy levels to set expeditious and adequate clinical decisions. The analytical technique Surface-enhanced Raman spectroscopy (SERS) possesses several properties that tailor to the POCT format, such as its flexibility to couple with rapid assay platforms like microfluidics and paper-based immunoassays. Here, we analyze the strategies used for the detection of cTnI by SERS considering POCT requirements. From the detection ranges reported in the reviewed literature, we suggest the diseases other than AMI that could be diagnosed with this technique. For this, a section with information about cardiac and non-cardiac diseases with cTnI release, including their release kinetics or cut-off values are presented. Likewise, POCT features, the use of SERS as a POCT technique, and the biochemistry of cTnI are discussed. The information provided in this review allowed the identification of strengths and lacks of the available SERS-based point-of-care tests for cTnI and the disclosing of requirements for future assays design.
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Affiliation(s)
- Anel I. Saviñon-Flores
- Centro de Química-ICUAP- Posgrado en Ciencias Ambientales, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | | | - G. Trejo
- Laboratory of Composite Materials and Functional Coatings, Center for Research and Technological Development in Electrochemistry (CIDETEQ), Querétaro, Mexico
| | - Erika Méndez
- Facultad de Ciencias Químicas, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Ştefan Ţălu
- Technical University of Cluj-Napoca, The Directorate of Research, Development and Innovation Management (DMCDI), Cluj-Napoca, Romania
| | - Miguel A. González-Fuentes
- Facultad de Ciencias Químicas, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
- *Correspondence: Miguel A. González-Fuentes, ; Alia Méndez-Albores,
| | - Alia Méndez-Albores
- Centro de Química-ICUAP- Posgrado en Ciencias Ambientales, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
- *Correspondence: Miguel A. González-Fuentes, ; Alia Méndez-Albores,
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4
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Santos-Gomes J, Gandra I, Adão R, Perros F, Brás-Silva C. An Overview of Circulating Pulmonary Arterial Hypertension Biomarkers. Front Cardiovasc Med 2022; 9:924873. [PMID: 35911521 PMCID: PMC9333554 DOI: 10.3389/fcvm.2022.924873] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH), also known as Group 1 Pulmonary Hypertension (PH), is a PH subset characterized by pulmonary vascular remodeling and pulmonary arterial obstruction. PAH has an estimated incidence of 15-50 people per million in the United States and Europe, and is associated with high mortality and morbidity, with patients' survival time after diagnosis being only 2.8 years. According to current guidelines, right heart catheterization is the gold standard for diagnostic and prognostic evaluation of PAH patients. However, this technique is highly invasive, so it is not used in routine clinical practice or patient follow-up. Thereby, it is essential to find new non-invasive strategies for evaluating disease progression. Biomarkers can be an effective solution for determining PAH patient prognosis and response to therapy, and aiding in diagnostic efforts, so long as their detection is non-invasive, easy, and objective. This review aims to clarify and describe some of the potential new candidates as circulating biomarkers of PAH.
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Affiliation(s)
- Joana Santos-Gomes
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Gandra
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Adão
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Frédéric Perros
- Paris-Porto Pulmonary Hypertension Collaborative Laboratory (3PH), UMR_S 999, INSERM, Université Paris-Saclay, Paris, France
- Université Paris–Saclay, AP-HP, INSERM UMR_S 999, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
| | - Carmen Brás-Silva
- UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
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5
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Banaszkiewicz M, Gąsecka A, Darocha S, Florczyk M, Pietrasik A, Kędzierski P, Piłka M, Torbicki A, Kurzyna M. Circulating Blood-Based Biomarkers in Pulmonary Hypertension. J Clin Med 2022; 11:jcm11020383. [PMID: 35054082 PMCID: PMC8779219 DOI: 10.3390/jcm11020383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/01/2022] [Accepted: 01/09/2022] [Indexed: 12/23/2022] Open
Abstract
Pulmonary hypertension (PH) is a serious hemodynamic condition, characterized by increased pulmonary vascular resistance (PVR), leading to right heart failure (HF) and death when not properly treated. The prognosis of PH depends on etiology, hemodynamic and biochemical parameters, as well as on response to specific treatment. Biomarkers appear to be useful noninvasive tools, providing information about the disease severity, treatment response, and prognosis. However, given the complexity of PH, it is impossible for a single biomarker to be adequate for the broad assessment of patients with different types of PH. The search for novel emerging biomarkers is still ongoing, resulting in a few potential biomarkers mirroring numerous pathophysiological courses. In this review, markers related to HF, myocardial remodeling, inflammation, hypoxia and tissue damage, and endothelial and pulmonary smooth muscle cell dysfunction are discussed in terms of diagnosis and prognosis. Extracellular vesicles and other markers with complex backgrounds are also reviewed. In conclusion, although many promising biomarkers have been identified and studied in recent years, there are still insufficient data on the application of multimarker strategies for monitoring and risk stratification in PH patients.
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Affiliation(s)
- Marta Banaszkiewicz
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
- Correspondence:
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.G.); (A.P.)
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Michał Florczyk
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.G.); (A.P.)
| | - Piotr Kędzierski
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Michał Piłka
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre Otwock, 05-400 Warsaw, Poland; (S.D.); (M.F.); (P.K.); (M.P.); (A.T.); (M.K.)
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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7
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Gaynitdinova VV, Avdeev SN. [Novel Biomarkers of Pulmonary Hypertension]. ACTA ACUST UNITED AC 2019; 59:84-94. [PMID: 31322094 DOI: 10.18087/cardio.2019.7.10259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension (PH) is a clinical syndrome characterized by a progressive increase in pulmonary vascular resistance (PVR), which leads to remodeling of the right ventricle (RV), right heart failure and premature death of patients. Early diagnosis and monitoring of disease progression are crucial for making decisions about the necessary therapy. The gold standard for the diagnosis of pulmonary hypertension is the right heart catheterization. The estimation of systolic pressure in pulmonary artery by means of transthoracic echocardiography is also used for monitoring the course of the disease. At present, there is still a need for non-invasive biomarkers that reflect pathological changes in pulmonary arterial vessels and allow diagnosing of PH. Our review outlines the new data about some biomarkers potentially useful for diagnosis and prognostication of PH. These biomarkers (mid-regional pro-adrenomedullin, carboxyterminal pro-endothelin-1, copeptin, asymmetric dimethylarginine, growth differentiation factor 15, and others) are classified based on their relationship to endothelial cell dysfunction, inflammation, epigenetics, cardiac function, oxidative stress, extracellular matrix. The determination of biomarkers that are of diagnostic value for predicting the severity, progression of PH and response to therapy, in a simple blood test or condensate of exhaled air, can significantly reduce treatment costs and improve PH management.
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Affiliation(s)
| | - S N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University); Pulmonology Research Institute
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8
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Xu SL, Yang J, Zhang CF, Xu SY, Zhao FY, Liu LQ, Xie CL, Xing XQ, Zhu Y. Serum cardiac troponin elevation predicts mortality in patients with pulmonary hypertension: A meta-analysis of eight cohort studies. CLINICAL RESPIRATORY JOURNAL 2019; 13:82-91. [PMID: 30636364 DOI: 10.1111/crj.12991] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/11/2018] [Accepted: 01/03/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Shuang-Lan Xu
- Department of Respiratory Medicine; The Fourth Affiliated Hospital of Kunming Medical University, The Second People’s Hospital of Yunnan Province; Kunming China
| | - Jiao Yang
- First Department of Respiratory Medicine; The First Affiliated Hospital of Kunming Medical University; Kunming China
| | - Chun-Fang Zhang
- Department of Respiratory Medicine; The Fourth Affiliated Hospital of Kunming Medical University, The Second People’s Hospital of Yunnan Province; Kunming China
| | - Shuang-Yan Xu
- Department of Dermatology; The Second Affiliated Hospital of Kunming Medical University; Kunming China
| | - Fang-Yun Zhao
- Department of Pharmacy; Yan’an Hospital Affiliated to Kunming Medical University; Kunming China
| | - Li-Qiong Liu
- First Department of Respiratory Medicine; Yan’an Hospital Affiliated to Kunming Medical University; Kunming China
| | - Chun-Lin Xie
- Department of Thoracici Surgery; The First Affiliated Hospital to Kunming Medical University; Kunming China
| | - Xi-Qian Xing
- Department of Respiratory Medicine; The Fourth Affiliated Hospital of Kunming Medical University, The Second People’s Hospital of Yunnan Province; Kunming China
| | - Yun Zhu
- The People’s Hospital of Yuxi City; The 6th Affiliated Hospital of Kunming Medical University; Yuxi China
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9
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Kriechbaum SD, Wiedenroth CB, Keller T, Wolter JS, Ajnwojner R, Peters K, Haas MA, Roller FC, Breithecker A, Rieth AJ, Guth S, Rolf A, Bandorski D, Hamm CW, Mayer E, Liebetrau C. Dynamics of high-sensitivity cardiac troponin T during therapy with balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13:e0204683. [PMID: 30252896 PMCID: PMC6155553 DOI: 10.1371/journal.pone.0204683] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/12/2018] [Indexed: 01/05/2023] Open
Abstract
Aims Balloon pulmonary angioplasty (BPA) is an interventional treatment modality for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Therapy monitoring, based on non-invasive biomarkers, is a clinical challenge. This post-hoc study aimed to assess dynamics of high-sensitivity cardiac troponin T (hs-cTnT) as a marker for myocardial damage and its relation to N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels as a marker for cardiac wall stress. Methods and results This study included 51 consecutive patients who underwent BPA treatment and completed a 6-month follow-up (6-MFU) between 3/2014 and 3/2017. Biomarker measurement was performed consecutively prior to each BPA and at 6-MFU. In total, the 51 patients underwent an average of 5 BPA procedures. The 6-month survival rate was 96.1%. The baseline (BL) meanPAP (39.5±12.1mmHg) and PVR (515.8±219.2dyn×sec×cm-5) decreased significantly within the 6-MFU (meanPAP: 32.6±12.6mmHg, P<0.001; PVR: 396.9±182.6dyn×sec×cm-5, P<0.001). At BL, the median hs-cTnT level was 11 (IQR 6–16) ng/L and the median NT-proBNP level was 820 (IQR 153–1872) ng/L. The levels of both biomarkers decreased steadily after every BPA, showing the first significant difference after the first procedure. Within the 6-MFU, hs-cTnT levels (7 [IQR 5–12] ng/L; P<0.001) and NT-proBNP levels (159 [IQR 84–464] ng/l; P<0.001) continued to decrease. The hs-cTnT levels correlated with the PVR (rrs = 0.42; p = 0.005), the meanPAP (rrs = 0.32; p = 0.029) and the NT-proBNP (rrs = 0.51; p<0.001) levels at BL. Conclusion Non-invasive biomarker measurement provides valuable evidence for the decreasing impairment of myocardial function and structure during BPA therapy. Changes in hs-cTNT levels are suggestive for a reduction in ongoing myocardial damage.
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Affiliation(s)
- Steffen D. Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- * E-mail:
| | | | - Till Keller
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Jan Sebastian Wolter
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Ruth Ajnwojner
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Karina Peters
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Moritz A. Haas
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Fritz C. Roller
- Justus Liebig University Giessen, Department of Radiology, Giessen, Germany
| | | | - Andreas J. Rieth
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Andreas Rolf
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Dirk Bandorski
- Justus Liebig University of Giessen, Department of Internal Medicine, Division of Pulmonology, Giessen, Germany
| | - Christian W. Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
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10
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Goldberg AB, Mazur W, Kalra DK. Pulmonary hypertension: diagnosis, imaging techniques, and novel therapies. Cardiovasc Diagn Ther 2017; 7:405-417. [PMID: 28890877 DOI: 10.21037/cdt.2017.04.11] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pulmonary hypertension (PH), defined as the elevation of mean pulmonary arterial pressure (mPAP) above 25 mmHg, has numerous causes, which the World Health Organization (WHO) has divided into five distinct categories based upon the underlying mechanism of action. This review will explore the pathophysiology, diagnostic testing, and treatment of PH. Identification of PH depends on a strong clinical suspicion, a detailed history, and a thorough physical exam. We review the evidence supporting experimental and clinical laboratory parameters for diagnosis and monitoring of PH. Transthoracic echocardiogram (TTE) is the initial screening test of choice. This review will detail specific echocardiographic techniques for the assessment and classification of PH. Furthermore, the importance of advanced imaging, including computed tomography (CT) and magnetic resonance imagining (MRI) is explored. New developments in pharmacology, percutaneous intervention, and surgical approaches are summarized. Finally, we will address the tools available to predict morbidity and mortality.
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Affiliation(s)
- Alan B Goldberg
- Department of Internal Medicine, Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Dinesh K Kalra
- Department of Internal Medicine, Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
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11
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Kohno T, Kataoka M, Kawakami T, Fukuoka R, Tamura Y, Kimura M, Takei M, Maekawa Y, Sano M, Fukuda K. Moderate-to-severe obstructive sleep apnea is associated with subclinical myocardial injury and impaired hemodynamics in pulmonary hypertension patients. Sleep Med 2017; 30:121-127. [DOI: 10.1016/j.sleep.2016.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/16/2015] [Accepted: 01/28/2016] [Indexed: 11/30/2022]
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12
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Kimura M, Kohno T, Kawakami T, Kataoka M, Tsugu T, Akita K, Isobe S, Itabashi Y, Maekawa Y, Murata M, Fukuda K. Midterm Effect of Balloon Pulmonary Angioplasty on Hemodynamics and Subclinical Myocardial Damage in Chronic Thromboembolic Pulmonary Hypertension. Can J Cardiol 2016; 33:463-470. [PMID: 28256427 DOI: 10.1016/j.cjca.2016.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The acute favourable effect of balloon pulmonary angioplasty (BPA) has been proven in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, data on its effect 6 months after therapy (from now on referred to as mid-term) and influence on the right ventricle and myocardial damage are sparse. To evaluate factors that influence improvement in cardiac output (CO) and subclinical myocardial damage, we examined hemodynamics and serum high-sensitivity troponin T (hs-TnT) levels before, 1 week after, and 6 months after BPA. METHODS In a retrospective study, we reviewed 67 consecutive patients from November 2012 to January 2016 with CTEPH who had undergone BPA at Keio University Hospital. RESULTS Six months after BPA, the mean right atrium pressure, mean pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), B-type natriuretic peptide (BNP), and hs-TnT levels decreased; CO and 6-minute walking distance increased. Changes in CO and hs-TnT levels varied compared with other hemodynamic parameters and BNP levels. The CO-increase group (n = 42) had higher mean PAP and PVR, and lower CO at baseline than the CO-decrease/stable group (n = 25). The hs-TnT-decrease group (n = 36) had higher mean right atrium pressure, PAP, PVR, and BNP levels, and lower CO at baseline than the hs-TnT-increase/stable group (n = 31). CONCLUSIONS Six months after BPA, hemodynamics and exercise capacity improved and hs-TnT levels decreased. Improvements in CO and hs-TnT levels were more prominent in CTEPH patients with impaired baseline hemodynamics, suggesting that BPA has a favourable mid-term effect on hemodynamics and subclinical myocardial damage in patients with CTEPH, especially in those with impaired hemodynamics.
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Affiliation(s)
- Mai Kimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Takashi Kawakami
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshimitsu Tsugu
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keitaro Akita
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Sarasa Isobe
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuji Itabashi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Maekawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsushige Murata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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13
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König K, Guy KJ, Nold-Petry CA, Barfield CP, Walsh G, Drew SM, Veldman A, Nold MF, Casalaz DM. BNP, troponin I, and YKL-40 as screening markers in extremely preterm infants at risk for pulmonary hypertension associated with bronchopulmonary dysplasia. Am J Physiol Lung Cell Mol Physiol 2016; 311:L1076-L1081. [PMID: 27760764 DOI: 10.1152/ajplung.00344.2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/13/2016] [Indexed: 11/22/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is often complicated by pulmonary hypertension (PH). We investigated three biomarkers potentially suitable as screening markers for extremely preterm infants at risk of BPD-associated PH. In this prospective observational cohort study conducted in a tertiary neonatal intensive care unit, 83 preterm infants with BPD born <28-wk gestation and still inpatients at 36-wk corrected age received an echocardiogram and blood tests of B-type natriuretic peptide (BNP), troponin I, and YKL-40. Infants were analyzed according to echocardiographic evidence of tricuspid regurgitation (TR). Thirty infants had evidence of TR on echocardiogram at 36-wk corrected age. Infants with or without TR had similar baseline demographics: mean ± SD gestational age 261 ± 12 vs. 261 ± 11 wk and birth weight 830 ± 206 vs. 815 ± 187 g, respectively. There was no difference in duration of respiratory support. The right ventricular systolic pressure of infants with evidence of TR was 40 ± 16 mmHg. BNP was the only biomarker that proved to be significantly higher in infants with evidence of TR: median (interquartile range) serum level 54.5 (35-105) vs. 41.5 (30-59) pg/ml, P = 0.043. Subgroup analysis of infants with severe BPD requiring discharge on home oxygen or BPD-related mortality revealed similar results. There was no difference between groups for troponin I and YKL-40. In conclusion, increased serum levels of BNP were associated with evidence of TR at 36-wk corrected gestational age in extremely preterm infants, suggesting a potential role as a screening biomarker for BPD-associated PH.
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Affiliation(s)
- Kai König
- Mercy Hospital for Women, Department of Paediatrics, Melbourne, Victoria, Australia;
| | - Katelyn J Guy
- Mercy Hospital for Women, Department of Paediatrics, Melbourne, Victoria, Australia
| | - Claudia A Nold-Petry
- Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; and.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Charles P Barfield
- Mercy Hospital for Women, Department of Paediatrics, Melbourne, Victoria, Australia
| | - Geraldine Walsh
- Mercy Hospital for Women, Department of Paediatrics, Melbourne, Victoria, Australia
| | - Sandra M Drew
- Mercy Hospital for Women, Department of Paediatrics, Melbourne, Victoria, Australia
| | - Alex Veldman
- Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; and.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Marcel F Nold
- Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; and.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Dan M Casalaz
- Mercy Hospital for Women, Department of Paediatrics, Melbourne, Victoria, Australia
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14
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Anwar A, Ruffenach G, Mahajan A, Eghbali M, Umar S. Novel biomarkers for pulmonary arterial hypertension. Respir Res 2016; 17:88. [PMID: 27439993 PMCID: PMC4955255 DOI: 10.1186/s12931-016-0396-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/04/2016] [Indexed: 12/29/2022] Open
Abstract
Pulmonary arterial hypertension is a deadly disease characterized by elevated pulmonary arterial pressures leading to right ventricular hypertrophy and failure. The confirmatory gold standard test is the invasive right heart catheterization. The disease course is monitored by pulmonary artery systolic pressure measurement via transthoracic echocardiography. A simple non-invasive test to frequently monitor the patients is much needed. Search for a novel biomarker that can be detected by a simple test is ongoing and many different options are being studied. Here we review some of the new and unique pre-clinical options for potential pulmonary hypertension biomarkers. These biomarkers can be broadly categorized based on their association with endothelial cell dysfunction, inflammation, epigenetics, cardiac function, oxidative stress, metabolism,extracellular matrix, and volatile compounds in exhaled breath condensate. A biomarker that can be detected in blood, urine or breath condensate and correlates with disease severity, progression and response to therapy may result in significant cost reduction and improved patient outcomes.
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Affiliation(s)
- Anjum Anwar
- Departmentof Anesthesiology, Stanford University, Palo Alto, CA, USA
| | - Gregoire Ruffenach
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Mansoureh Eghbali
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
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15
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Right atrial emptying fraction non-invasively predicts mortality in pulmonary hypertension. Int J Cardiovasc Imaging 2016; 32:1121-30. [PMID: 27076226 DOI: 10.1007/s10554-016-0883-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 03/24/2016] [Indexed: 12/21/2022]
Abstract
Right-sided heart failure is the most common cause of death in pulmonary hypertension (PH). Echocardiographic measurements of right atrial (RA) size are associated with worse outcome in PH, however the association between RA function and death in PH has not been well-described. 160 PH patients (World Health Organization groups 1-5) underwent cardiac magnetic resonance imaging (cMRI) and right heart catheterization (RHC) within 6 weeks of each other at a tertiary care academic medical center in the United States. We measured cMRI RA maximum and minimum volumes indexed to body surface area and calculated RA emptying fraction (RAEF). We evaluated the relationship between RAEF and clinical variables with death using Cox proportional hazard models. 57 deaths occurred during a median follow-up of 3.5 years (36 % died overall, 10 % per year). RAEF was directly correlated in univariate analyses with right ventricular (RV) ejection fraction, left ventricular (LV) ejection fraction, LV size, cardiac index, absence of tricuspid and pulmonic regurgitation, absence of pericardial effusion, estimated glomerular filtration rate, 6-minute walk distance, and pulmonary arterial oxygen saturation, whereas it was inversely correlated with death, BNP, heart rate, mean RA pressure, mean PA pressure, pulmonary and systemic vascular resistance, RV size, and RA size. Using multivariate analyses, RAEF had a robust inverse association with death after adjusting for measured risk factors (HR per 5 % change in RAEF: 0.83 [95 % CI 0.73-0.94], p = 0.003). In PH patients, decreased RAEF by cMRI is independently associated with worse survival after adjustment for other risk factors.
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16
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Kimura M, Kohno T, Kawakami T, Kataoka M, Inohara T, Takei M, Tsugu T, Murata M, Maekawa Y, Fukuda K. Balloon pulmonary angioplasty attenuates ongoing myocardial damage in patients with chronic thromboembolic pulmonary hypertension. Int J Cardiol 2015; 207:387-9. [PMID: 26602928 DOI: 10.1016/j.ijcard.2015.11.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/31/2015] [Accepted: 11/04/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Mai Kimura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Takashi Kawakami
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masaharu Kataoka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Takei
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshimitsu Tsugu
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsushige Murata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Maekawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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17
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Klok F, Tesche C, Rappold L, Dellas C, Hasenfuß G, Huisman M, Konstantinides S, Lankeit M. External validation of a simple non-invasive algorithm to rule out chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Thromb Res 2015; 135:796-801. [DOI: 10.1016/j.thromres.2014.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/03/2014] [Accepted: 12/06/2014] [Indexed: 01/21/2023]
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18
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19
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Peripheral blood miRNAs as a biomarker for chronic cardiovascular diseases. Sci Rep 2014; 4:5026. [PMID: 24848278 PMCID: PMC4052773 DOI: 10.1038/srep05026] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 04/22/2014] [Indexed: 12/26/2022] Open
Abstract
Vascular diseases are the most prevalent diseases worldwide. This study intended to analyze peripheral blood miRNA levels and their correlation with NT-pro-BNP and cTN-I in patients with atherosclerosis or pre-atherosclerotic conditions to build a dynamic correlation between vascular diseases and their biomarkers. Serum NT-pro-BNP and cTN-I levels were measured by their respective ELISA kits. The miRNA levels were assayed by quantitative PCR. Unique miRNA signatures were identified for both atherosclerosis and pre-atherosclerosis. The levels of miR-92a, 126, 130a, 222, and 370 levels were decreased in the peripheral blood of pre-atherosclerotic subjects. In atherosclerosis, miR-21, 122, 130a, and 211 were significantly increased whereas miR-92a, 126, and 222 were markedly decreased. Serum levels of NT-pro-BNP and cTN-I correlated with each other and increased with the progression of atherosclerosis. Moreover, the levels of cTN-I and NT-pro-BNP were positively correlated with miR-21 and negatively correlated with miR-126. Integrating specific pattern of miRNA levels with NT-pro-BNP and/or cardiac troponin may improve the diagnosis of cardiovascular diseases.
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20
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Vonk-Noordegraaf A, Haddad F, Chin KM, Forfia PR, Kawut SM, Lumens J, Naeije R, Newman J, Oudiz RJ, Provencher S, Torbicki A, Voelkel NF, Hassoun PM. Right heart adaptation to pulmonary arterial hypertension: physiology and pathobiology. J Am Coll Cardiol 2014; 62:D22-33. [PMID: 24355638 DOI: 10.1016/j.jacc.2013.10.027] [Citation(s) in RCA: 674] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/22/2013] [Indexed: 12/22/2022]
Abstract
Survival in patients with pulmonary arterial hypertension (PAH) is closely related to right ventricular (RV) function. Although pulmonary load is an important determinant of RV systolic function in PAH, there remains a significant variability in RV adaptation to pulmonary hypertension. In this report, the authors discuss the emerging concepts of right heart pathobiology in PAH. More specifically, the discussion focuses on the following questions. 1) How is right heart failure syndrome best defined? 2) What are the underlying molecular mechanisms of the failing right ventricle in PAH? 3) How are RV contractility and function and their prognostic implications best assessed? 4) What is the role of targeted RV therapy? Throughout the report, the authors highlight differences between right and left heart failure and outline key areas of future investigation.
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Affiliation(s)
| | - François Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Kelly M Chin
- Department of Internal Medicine, Pulmonary Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul R Forfia
- Pulmonary Hypertension and Right Heart Failure Program, Temple University Hospital, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Robert Naeije
- Department of Pathophysiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium
| | - John Newman
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ronald J Oudiz
- The David Geffen School of Medicine at UCLA, Liu Center for Pulmonary Hypertension, Division of Cardiology, Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Steve Provencher
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Chemin Sainte-Foy, Québec, Canada
| | - Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of Postgraduate Medical Education, ECZ, Otwock, Poland
| | - Norbert F Voelkel
- Division of Pulmonary and Critical Care Medicine and Victoria Johnson Lab for Lung Research, Virginia Commonwealth University, Richmond, Virginia; Johns Hopkins University, Baltimore, Maryland
| | - Paul M Hassoun
- Department of Internal Medicine, Pulmonary Division, University of Texas Southwestern Medical Center, Dallas, Texas
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21
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Gamble JHP, Carlton EW, Orr WP, Greaves K. High-sensitivity cardiac troponins: no more 'negatives'. Expert Rev Cardiovasc Ther 2013; 11:1129-39. [PMID: 23977868 DOI: 10.1586/14779072.2013.828978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
According to recently published expert guidelines, cardiac troponins are the only accepted biomarkers to define acute myocardial infarction. New high sensitivity cardiac troponin assays provide exciting opportunities for early rule-out and rule-in strategies and for identifying high-risk patients early in their presentation to guide early treatment and intervention. This review briefly discusses the history of troponin testing, before going on to cover clinical uses of the new highly sensitive assays in the early assessment of acute myocardial infection. Common clinical pitfalls with the use of these assays are discussed, as is the use of highly sensitive troponins more widely as prognostic markers. Likely future developments in this area are discussed.
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Affiliation(s)
- James H P Gamble
- Cardiovascular Clinical Research Facility, John Radcliffe Hospital, Oxford OX3 9DU, UK
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