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Ley L, Grimminger F, Richter M, Tello K, Ghofrani A, Bandorski D. The Early Detection of Pulmonary Hypertension. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:823-830. [PMID: 37882345 PMCID: PMC10853922 DOI: 10.3238/arztebl.m2023.0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Up to 1% of the world population and 10% of all persons over age 65 suffer from pulmonary hypertension (PH). The latency from the first symptom to the diagnosis is more than one year on average, and more than three years in 20% of patients. 40% seek help from more than four different physicians until their condition is finally diagnosed. METHODS This review is based on publications retrieved by a selective literature search on pulmonary hypertension. RESULTS The most common causes of pulmonary hypertension are left heart diseases and lung diseases. Its cardinal symptom is exertional dyspnea that worsens as the disease progresses. Additional symptoms of right heart failure are seen in advanced stages. Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are rare, difficult to diagnose, and of particular clinical relevance because specific treatments are available. For this reason, strategies for the early detection of PAH and CTEPH have been developed. The clinical suspicion of PH arises in a patient who has nonspecific symptoms, electrocardiographic changes, and an abnormal (NT-pro-)BNP concentration. Once the suspicion of PH has been confirmed by echocardiography and, if necessary, differential-diagnostic evaluation with a cardiopulmonary stress test, and after the exclusion of a primary left heart disease or lung disease, the patient should be referred to a PH center for further diagnostic assessment, classification, and treatment. CONCLUSION If both the (NT-pro-)BNP and the ECG are normal, PH is unlikely. Knowledge of the characteristic clinical manifestations and test results of PH is needed so that patients can be properly selected for referral to specialists and experts in PH.
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Affiliation(s)
- Lukas Ley
- Justus-Liebig-University Gießen, Campus Kerckhoff, Bad Nauheim
| | | | | | | | | | - Dirk Bandorski
- Semmelweis University, Department of Medicine, 20099 Hamburg
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2
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Baratto C, Caravita S, Vachiéry JL. Pulmonary Hypertension Associated with Left Heart Disease. Semin Respir Crit Care Med 2023; 44:810-825. [PMID: 37709283 DOI: 10.1055/s-0043-1772754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure, with or without preserved left ventricular ejection fraction. Initially driven by a passive increase in left atrial pressure (postcapillary PH), several mechanisms may lead in a subset of patient to significant structural changes of the pulmonary vessels or a precapillary component. In addition, the right ventricle may be independently affected, which results in right ventricular to pulmonary artery uncoupling and right ventricular failure, all being associated with a worse outcome. The differential diagnosis of PH associated with left heart disease versus pulmonary arterial hypertension (PAH) is especially challenging in patients with cardiovascular comorbidities and/or heart failure with preserved ejection fraction (HFpEF). A stepwise approach to diagnosis is proposed, starting with a proper clinical multidimensional phenotyping to identify patients in whom hemodynamic confirmation is deemed necessary. Provocative testing (exercise testing, fluid loading, or simple leg raising) is useful in the cath laboratory to identify patients with abnormal response who are more likely to suffer from HFpEF. In contrast with group 1 PH, management of PH associated with left heart disease must focus on the treatment of the underlying condition. Some PAH-approved targets have been unsuccessfully tried in clinical studies in a heterogeneous group of patients, some even leading to an increase in adverse events. There is currently no approved therapy for PH associated with left heart disease.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, HUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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3
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D'Alto M, Liccardo B, Di Maio M, Del Giudice C, Romeo E, Argiento P, Renon F, Vergara A, Di Vilio A, Caiazza E, Bossone E, Rea G, D'Andrea A, Gargani L, Golino P, Naeije R. Lung Ultrasound, Echocardiography, and Fluid Challenge for the Differential Diagnosis of Pulmonary Hypertension. J Am Soc Echocardiogr 2023; 36:1181-1189. [PMID: 37544385 DOI: 10.1016/j.echo.2023.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES The differential diagnosis between pulmonary arterial hypertension (PAH) and postcapillary pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF) is sometimes difficult despite guidelines-derived standardized step-by-step diagnostic algorithms. We therefore explored the added value of lung ultrasound to a previously validated echocardiographic score of right heart catheterization measurements. METHODS Patients referred for PH underwent a right heart catheterization, echocardiography, and lung ultrasound before and after rapid infusion of 7 mL/kg of saline. A 7-point echocardiographic score based on cardiac chamber dimensions and estimates of filling pressures was implemented for the prediction of precapillary PH. Pulmonary congestion was identified by lung ultrasound B lines. RESULTS The study enrolled 70 patients with PAH and 77 patients with HFpEF. The PAH patients had a higher echocardiographic score (3.5 ± 1.8 vs 1.6 ± 1.5; P < .001). The HFpEF patients had more B lines both before (8.1 ± 4.2 vs 5.1 ± 3.0; P < .001) and after fluid challenge (14.6 ± 5.4 vs 7.6 ± 3.5; P < .001) and a more important increase (Δ) of B lines after fluid challenge (6.5 ± 2.9 vs 2.5 ± 1.6; P < .001). The sensitivity and specificity of the echocardiographic score (cutoff ≥2) alone for PAH were 0.91 and 0.49, respectively (area under the curve of 0.78). The best diagnostic improvement was observed with addition of ΔB lines + E/e' post-fluid challenge to the echocardiographic score, with a significant increase of the area under the curve (0.98) and (with a cutoff given by the presence of echo score ≥2, ΔB lines <4 and E/e' post < 11) a sensitivity of 0.90 (95% CI, 0.83; 0.97) and specificity of 0.84 (95% CI, 0.76; 0.93). CONCLUSIONS Lung ultrasound combined with echocardiography at baseline and after fluid challenge has an incremental value for the differential diagnosis between PAH and PH-HFpEF.
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Affiliation(s)
- Michele D'Alto
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy.
| | - Biagio Liccardo
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Carmen Del Giudice
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Emanuele Romeo
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Paola Argiento
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Francesca Renon
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Andrea Vergara
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Alessandro Di Vilio
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Eleonora Caiazza
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Eduardo Bossone
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Gaetano Rea
- Radiology Unit, Monaldi Hospital, Naples, Italy
| | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, "Umberto I" Hospital, Nocera Inferiore, Italy
| | - Luna Gargani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Paolo Golino
- Department of Cardiology, University of Campania "L. Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Robert Naeije
- Department of Pathophysiology, Free University of Bruxelles, Bruxelles, Belgium
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4
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Swinnen K, Verstraete K, Baratto C, Hardy L, De Vos M, Topalovic M, Claessen G, Quarck R, Belge C, Vachiery JL, Janssens W, Delcroix M. Machine learning to differentiate pulmonary hypertension due to left heart disease from pulmonary arterial hypertension. ERJ Open Res 2023; 9:00229-2023. [PMID: 37727672 PMCID: PMC10505948 DOI: 10.1183/23120541.00229-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/04/2023] [Indexed: 09/21/2023] Open
Abstract
Background and aims Pulmonary hypertension due to left heart disease (PH-LHD) is the most frequent form of PH. As differential diagnosis with pulmonary arterial hypertension (PAH) has therapeutic implications, it is important to accurately and noninvasively differentiate PH-LHD from PAH before referral to PH centres. The aim was to develop and validate a machine learning (ML) model to improve prediction of PH-LHD in a population of PAH and PH-LHD patients. Methods Noninvasive PH-LHD predictors from 172 PAH and 172 PH-LHD patients from the PH centre database at the University Hospitals of Leuven (Leuven, Belgium) were used to develop an ML model. The Jacobs score was used as performance benchmark. The dataset was split into a training and test set (70:30) and the best model was selected after 10-fold cross-validation on the training dataset (n=240). The final model was externally validated using 165 patients (91 PAH, 74 PH-LHD) from Erasme Hospital (Brussels, Belgium). Results In the internal test dataset (n=104), a random forest-based model correctly diagnosed 70% of PH-LHD patients (sensitivity: n=35/50), with 100% positive predicted value, 78% negative predicted value and 100% specificity. The model outperformed the Jacobs score, which identified 18% (n=9/50) of the patients with PH-LHD without false positives. In external validation, the model had 64% sensitivity at 100% specificity, while the Jacobs score had a sensitivity of 3% for no false positives. Conclusions ML significantly improves the sensitivity of PH-LHD prediction at 100% specificity. Such a model may substantially reduce the number of patients referred for invasive diagnostics without missing PAH diagnoses.
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Affiliation(s)
- Katleen Swinnen
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- These authors contributed equally
| | - Kenneth Verstraete
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
- These authors contributed equally
| | - Claudia Baratto
- Department of Cardiology, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Laura Hardy
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Maarten De Vos
- STADIUS Center for Dynamical Systems, Signal Processing and Data Analytics, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Guido Claessen
- Department of Cardiology, University Hospitals of Leuven, Leuven, Belgium
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
| | - Catharina Belge
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
| | - Jean-Luc Vachiery
- Department of Cardiology, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Wim Janssens
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, BREATHE, CHROMETA, KU Leuven, Leuven, Belgium
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Gong C, Guo X, Wan K, Chen C, Chen X, Guo J, He J, Yin L, Wen B, Pu S, Chen Y. Corrected MRI Pulmonary Transit Time for Identification of Combined Precapillary and Postcapillary Pulmonary Hypertension in Patients With Left Heart Disease. J Magn Reson Imaging 2022; 57:1518-1528. [PMID: 37021578 DOI: 10.1002/jmri.28386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The identification of combined precapillary and postcapillary pulmonary hypertension (CpcPH) in patients with pulmonary hypertension (PH) due to left heart disease (LHD) can influence therapy and outcome and is currently based on invasively determined hemodynamic parameters. PURPOSE To investigate the diagnostic value of MRI-derived corrected pulmonary transit time (PTTc) in PH-LHD sub-grouped according to hemodynamic phenotypes. STUDY TYPE Prospective observational study. POPULATION A total of 60 patients with PH-LHD (18 with isolated postcapillary PH [IpcPH] and 42 with CpcPH), and 33 healthy subjects. FIELD STRENGTH/SEQUENCE A 3.0 T/balanced steady-state free precession cine and gradient echo-train echo planar pulse first-pass perfusion. ASSESSMENT In patients, right heart catheterization (RHC) and MRI were performed within 30 days. Pulmonary vascular resistance (PVR) was used as the diagnostic "reference standard." The PTTc was calculated as the time interval between the peaks of the biventricular signal-intensity/time curve and corrected for heart rate. PTTc was compared between patient groups and healthy subjects and its relationship to PVR assessed. The diagnostic accuracy of PTTc for distinguishing IpcPH and CpcPH was determined. STATISTICAL TESTS Student's t-test, Mann-Whitney U-test, linear and logistic regression analysis, and receiver-operating characteristic curves. Significance level: P < 0.05. RESULTS PTTc was significantly prolonged in CpcPH compared with IpcPH and normal controls (17.28 ± 7.67 vs. 8.82 ± 2.55 vs. 6.86 ± 2.11 seconds), and in IpcPH compared with normal controls (8.82 ± 2.55 vs. 6.86 ± 2.11 seconds). Prolonged PTTc was significantly associated with increased PVR. Furthermore, PTTc was a significantly independent predictor of CpcPH (odds ratio: 1.395, 95% confidence interval: 1.071-1.816). The area under curve was 0.852 at a cut-off value of 11.61 seconds for PTTc to distinguish between CpcPH and IpcPH (sensitivity 71.43% and specificity 94.12%). DATA CONCLUSION PTTc may be used to identify CpcPH. Our findings have potential to improve selection for invasive RHC for PH-LHD patients. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Chao Gong
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Xinli Guo
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Ke Wan
- Department of Geriatrics, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Chen Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Xiaoling Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Jiajun Guo
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Juan He
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Lidan Yin
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Bi Wen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Shoufang Pu
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
| | - Yucheng Chen
- Cardiology Division, West China Hospital Sichuan University Chengdu Sichuan Province China
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Lee JH, Park JH, Hwang IC, Park JJ, Park JB. Decreased Peak Left Atrial Longitudinal Strain Is Associated with Persistent Pulmonary Hypertension Associated with Left Heart Disease. J Clin Med 2022; 11:3510. [PMID: 35743580 PMCID: PMC9225174 DOI: 10.3390/jcm11123510] [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: 03/28/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 02/05/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart disease (PH-LHD) is the most common form of PH and has significantly higher morbidity and mortality. We estimated the prevalence of PH-LHD on the follow-up echocardiography and the role of left atrial (LA) function in PH-LHD. From the STRATS-AHF registry composed of 4312 acute heart failure (HF) patients, we analyzed peak atrial longitudinal strain (PALS) in 1729 patients with follow-up echocardiographic examinations during mean 18.1 ± 13.5 months. PH was determined by the maximal velocity of tricuspid regurgitation (TR Vmax ≥ 3.4 m/s). Persistent PH was found in 373 patients (21.6%). The PH-LHD group was significantly older, and the prevalence of atrial fibrillation (AF), hypertension, diabetes, and heart failure with preserved ejection fraction were higher compared with the no PH-LHD group. Baseline left ventricular end-systolic volume and PALS were lower, and LA diameter, mitral E/E’ ratio, and TR Vmax were higher in the PH-LHD group. In the multivariate analysis, PALS (HR = 1.024, p = 0.040) was a significant variable after adjustment of LA diameter and mitral E/E’. A decreased PALS of <12.5% was the best cutoff value in the prediction of persistent PH-LHD (AUC = 0.594, sensitivity = 65.3%, specificity = 46.1%). PH-LHD was associated with increased HF hospitalization (HR = 2.344, p < 0.001) and mortality (HR = 2.015, p < 0.001) after adjusting for age and sex. In conclusion, persistent PH-LHD was found in 21.6% in the follow-up echocardiography and was associated with decreased PALS (<12.5%). PH-LHD persistence was associated with poor clinical outcomes. Thus, AHF patients with decreased PALS, especially <12.5%, should be followed with caution.
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Affiliation(s)
- Ju-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, Korea;
| | - Jae-Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 35015, Korea
| | - In-Chang Hwang
- Department of Cardiology, Cardiovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (I.-C.H.); (J.J.P.)
| | - Jin Joo Park
- Department of Cardiology, Cardiovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (I.-C.H.); (J.J.P.)
| | - Jun-Bean Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Korea;
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Maron BA, Humbert M. HFp2EF: heart failure with pulmonary dysfunction and preserved ejection fraction? Eur Heart J 2022; 43:2209-2211. [PMID: 35466998 DOI: 10.1093/eurheartj/ehac201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School and the Department of Cardiology, VA Boston Healthcare System, Boston, MA, USA
| | - Marc Humbert
- Université Paris-Saclay, INSERM UMR_S 999, AP-HP, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Structural and Hemodynamic Changes of the Right Ventricle in PH-HFpEF. Int J Mol Sci 2022; 23:ijms23094554. [PMID: 35562945 PMCID: PMC9103781 DOI: 10.3390/ijms23094554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022] Open
Abstract
One of the most important diagnostic challenges in clinical practice is the distinction between pulmonary hypertension (PH) due to primitive pulmonary arterial hypertension (PAH) and PH due to left heart diseases. Both conditions share some common characteristics and pathophysiological pathways, making the two processes similar in several aspects. Their diagnostic differentiation is based on hemodynamic data on right heart catheterization, cardiac structural modifications, and therapeutic response. More specifically, PH secondary to heart failure with preserved ejection fraction (HFpEF) shares features with type 1 PH (PAH), especially when the combined pre- and post-capillary form (CpcPH) takes place in advanced stages of the disease. Right ventricular (RV) dysfunction is a common consequence related to worse prognosis and lower survival. This condition has recently been identified with a new classification based on clinical signs and progression markers. The role and prevalence of PH and RV dysfunction in HFpEF remain poorly identified, with wide variability in the literature reported from the largest clinical trials. Different parenchymal and vascular alterations affect the two diseases. Capillaries and arteriole vasoconstriction, vascular obliteration, and pulmonary blood fluid redistribution from the basal to the apical district are typical manifestations of type 1 PH. Conversely, PH related to HFpEF is primarily due to an increase of venules/capillaries parietal fibrosis, extracellular matrix deposition, and myocyte hypertrophy with a secondary “arteriolarization” of the vessels. Since the development of structural changes and the therapeutic target substantially differ, a better understanding of pathobiological processes underneath PH-HFpEF, and the identification of potential maladaptive RV mechanisms with an appropriate diagnostic tool, become mandatory in order to distinguish and manage these two similar forms of pulmonary hypertension.
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Dzikowska-Diduch O, Kurnicka K, Lichodziejewska B, Zdończyk O, Dąbrowska D, Roik M, Pacho S, Bielecki M, Pruszczyk P. A Novel Doppler TRPG/AcT Index Improves Echocardiographic Diagnosis of Pulmonary Hypertension after Pulmonary Embolism. J Clin Med 2022; 11:1072. [PMID: 35207345 PMCID: PMC8879629 DOI: 10.3390/jcm11041072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/13/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). METHODS We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. RESULTS Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100-2.197) vs. 0.208 (0.026-0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731-0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25-1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. CONCLUSIONS A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH.
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Affiliation(s)
- Olga Dzikowska-Diduch
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Katarzyna Kurnicka
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Barbara Lichodziejewska
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Olga Zdończyk
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Dominika Dąbrowska
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Marek Roik
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Szymon Pacho
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
| | - Maksymilian Bielecki
- Department of Psychology, SWPS University of Social Sciences and Humanities, 03-815 Warsaw, Poland;
| | - Piotr Pruszczyk
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.K.); (B.L.); (O.Z.); (D.D.); (M.R.); (S.P.); (P.P.)
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10
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Fontes Oliveira M, Oliveira MI, Furtado I, Carvalho L, Gonçalves F, Reis A, Santos M. External validation of different clinical and echocardiographic scores to distinguish post- from precapillary pulmonary hypertension. Echocardiography 2021; 38:1558-1566. [PMID: 34355812 DOI: 10.1111/echo.15172] [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: 02/07/2021] [Revised: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Even though right heart catheterization (RHC) is the gold-standard method to characterise Pulmonary Hypertension (PH), it cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to differentiate PH secondary to heart failure with preserved ejection fraction (PH-HFpEF) from pre-capillary PH. We aimed to compare the performance of non-invasive parameters in a population with suspected PH. METHODS We retrospectively included consecutive patients who underwent RHC for suspected PH. Patients with a non-invasive evaluation clearly suggestive of left heart disease were excluded. We assessed the performance of non-invasive pulmonary vascular resistance (PVR), echocardiographic pulmonary to left atrial ratio (ePLAR), and Opotowsky, Richter, Berthelot, and D'Alto scores using the area under curve (AUC) of the receiver operating characteristic curves. RESULTS Of the 142 included patients, 61 patients had pre-capillary PH, 49 had PH-HFpEF, and 32 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in 71-100% of our patients. Using the original cut-offs, Opotowsky was the score that best predicted precapillary PH (96% sensitivity, 41% specificity, AUC .69), followed by D'Alto (98% sensitivity, 22% specificity, AUC .60) and Berthelot (32% sensitivity, 90% specificity, AUC .60). Richter score did not discriminate between phenotypes (AUC .50). Using optimised cut-offs, a Berthelot score < 9 predicted precapillary PH with 73% sensitivity and 74% specificity (AUC .73). Single echocardiographic parameters as non-invasive PVR (85% sensitivity, 59% specificity, AUC .72) and ePLAR (73% sensitivity, 76% specificity, AUC .75) showed better prediction performance than the composite studied scores. CONCLUSION Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with moderate performance. The application of these non-invasive parameters in clinical practice can help refine referral to RHC in a population with clinically suspected PH.
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Affiliation(s)
- Marta Fontes Oliveira
- Cardiology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Maria Isilda Oliveira
- Centre of Physical Activity, Health and Leisure, Faculdade de Desporto da Universidade do Porto, R. Dr. Plácido da Costa 91, Porto, Portugal
| | - Inês Furtado
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Luísa Carvalho
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Fabienne Gonçalves
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Abílio Reis
- Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
| | - Mário Santos
- Cardiology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal.,Pulmonary Vascular Disease Unit, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, Portugal
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11
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Maeder MT, Weber L, Buser M, Brenner R, Joerg L, Rickli H. Pulmonary Hypertension in Patients With Heart Failure With Mid-Range Ejection Fraction. Front Cardiovasc Med 2021; 8:694240. [PMID: 34307506 PMCID: PMC8298862 DOI: 10.3389/fcvm.2021.694240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
Pulmonary hypertension (PH) is common in patients with heart failure (HF). The role of PH in patients with HF with reduced (HFrEF) and preserved (HFpEF) left ventricular ejection fraction (LVEF) has been extensively characterized during the last years. In contrast, the pathophysiology of HF with mid-range LVEF (HFmrEF), and in particular the role of PH in this context, are largely unknown. There is a paucity of data in this field, and the prevalence of PH, the underlying mechanisms, and the optimal therapy are not well-defined. Although often studied together there is increasing evidence that despite similarities with both HFrEF and HFpEF, HFmrEF also differs from both entities. The present review provides a summary of the current concepts of the mechanisms and clinical impact of PH in patients with HFmrEF, a proposal for the non-invasive and invasive diagnostic approach required to define the pathophysiology of PH and its management, and a discussion of future directions based on insights from mechanistic studies and randomized trials. We also provide an outlook regarding gaps in evidence, future clinical challenges, and research opportunities.
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Affiliation(s)
- Micha T. Maeder
- Cardiology Department, Kantonsspital St. Gallen, St. Gallen, Switzerland
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12
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Kanwar MK, Tedford RJ, Thenappan T, De Marco T, Park M, McLaughlin V. Elevated Pulmonary Pressure Noted on Echocardiogram: A Simplified Approach to Next Steps. J Am Heart Assoc 2021; 10:e017684. [PMID: 33719491 PMCID: PMC8174323 DOI: 10.1161/jaha.120.017684] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/04/2021] [Indexed: 02/02/2023]
Abstract
An elevated right ventricular/pulmonary artery systolic pressure suggestive of pulmonary hypertension (PH) is a common finding noted on echocardiography and is considered a marker for poor clinical outcomes, regardless of the cause. Even mild elevation of pulmonary pressure can be considered a modifiable risk factor, informing the trajectory of patients' clinical outcome. Although guidelines have been published detailing diagnostic and management algorithms, this echocardiographic finding is often underappreciated or not acted upon. Hence, patients with PH are often diagnosed in clinical practice when hemodynamic abnormalities are already moderate or severe. This results in delayed initiation of potentially effective therapies, referral to PH centers, and greater patient morbidity and mortality. This mini-review presents a succinct, simplified case-based approach to the "next steps" in the work-up of PH, once elevated pulmonary pressures have been noted on an echocardiogram. Our goal is for clinicians to develop a good overview of diagnostic approach to PH and recognition of high-risk features that may require early referral.
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Affiliation(s)
| | - Ryan J. Tedford
- Department of MedicineMedical University of South CarolinaCharlestonSC
| | | | | | - Myung Park
- Cardiovascular DiseaseCHI FranciscanTacomaWA
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13
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Lee F, Mielniczuk LM. Pulmonary Hypertension Due to Left Heart Disease-A Practical Approach to Diagnosis and Management. Can J Cardiol 2020; 37:572-584. [PMID: 33217522 DOI: 10.1016/j.cjca.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/01/2020] [Accepted: 11/10/2020] [Indexed: 01/07/2023] Open
Abstract
Pulmonary hypertension (PH) due to left heart disease (LHD) is a frequent complication of heart failure (HF) and is associated with exercise intolerance, poor quality of life, increased risk of hospitalisations, and reduced overall survival. Since the recent Sixth World Symposium on Pulmonary Hypertension in 2018, there have been significant changes in the hemodynamic definitions and clinical classification of PH-LHD. PH-LHD can be subdivided into (1) isolated postcapillary PH (IpcPH) and (2) combined precapillary and postcapillary PH (CpcPH). This categorisation of PH-LHD is important because CpcPH shares certain pathophysiologic, clinical, and hemodynamic characteristics with pulmonary arterial hypertension and is associated with worse outcomes compared with IpcPH. A systematic approach using clinical history and noninvasive investigations is required in the diagnosis of PH-LHD. Right heart catheterisation with and without provocative testing is performed in expert centres and is indicated in selected individuals. Although the definition of IpcPH and CpcPH is based on measurements made with right heart catheterisation, distinguishing between these two entities is not always necessary. Despite strong evidence for medical therapy in patients with pulmonary arterial hypertension, those options have limited benefit in PH-LHD. Expert PH centres in Canada have been established to provide ongoing care for the more complex patient subgroups.
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Affiliation(s)
- Felicity Lee
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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14
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Bernardo RJ, Haddad F, Couture EJ, Hansmann G, de Jesus Perez VA, Denault AY, de Man FS, Amsallem M. Mechanics of right ventricular dysfunction in pulmonary arterial hypertension and heart failure with preserved ejection fraction. Cardiovasc Diagn Ther 2020; 10:1580-1603. [PMID: 33224775 PMCID: PMC7666917 DOI: 10.21037/cdt-20-479] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Abstract
Right ventricular (RV) dysfunction is the most important determinant of survival in patients with pulmonary hypertension (PH). The manifestations of RV dysfunction not only include changes in global RV systolic function but also abnormalities in the pattern of contraction and synchrony. The effects of PH on the right ventricle have been mainly studied in patients with pulmonary arterial hypertension (PAH). However, with the demographic shift towards an aging population, heart failure with preserved ejection fraction (HFpEF) has become an important etiology of PH in recent years. There are significant differences in RV mechanics, function and adaptation between patients with PAH and HFpEF (with or without PH), which are related to different patterns of remodeling and dysfunction. Due to the unique features of the RV chamber, its connection with the main pulmonary artery and the pulmonary circulation, an understanding of the mechanics of RV function and its clinical significance is mandatory for both entities. In this review, we describe the mechanics of the pressure overloaded right ventricle. We review the different mechanical components of RV dysfunction and ventricular dyssynchrony, followed by insights via analysis of pressure-volume loop, energetics and novel blood flow patterns, such as vortex imaging. We conduct an in-depth comparison of prevalence and characteristics of RV dysfunction in HFpEF and PAH, and summarize key outcome studies. Finally, we provide a perspective on needed and expected future work in the field of RV mechanics.
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Affiliation(s)
- Roberto J. Bernardo
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Etienne J. Couture
- Department of Anesthesiology, Quebec Heart and Lung Institute, Quebec, Canada
- Intensive Care Medicine Division, Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Quebec, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Vinicio A. de Jesus Perez
- Division of Pulmonary, Allergy and Critical Care, Stanford University School of Medicine, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
| | - André Y. Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal, Canada
| | - Frances S. de Man
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, PHEniX laboratory, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Myriam Amsallem
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, CA, USA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
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15
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Hirani N, Brunner NW, Kapasi A, Chandy G, Rudski L, Paterson I, Langleben D, Mehta S, Mielniczuk L. Canadian Cardiovascular Society/Canadian Thoracic Society Position Statement on Pulmonary Hypertension. Can J Cardiol 2020; 36:977-992. [DOI: 10.1016/j.cjca.2019.11.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
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16
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Beyond the myocardium? SGLT2 inhibitors target peripheral components of reduced oxygen flux in the diabetic patient with heart failure with preserved ejection fraction. Heart Fail Rev 2020; 27:219-234. [PMID: 32583230 DOI: 10.1007/s10741-020-09996-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Recent cardiovascular outcome trials have highlighted the propensity of the antidiabetic agents, SGLT2 inhibitors (SGLT2is or -flozin drugs), to exert positive clinical outcomes in patients with cardiovascular disease at risk for major adverse cardiovascular events (MACEs). Of interest in cardiac diabetology is the physiological status of the patient with T2DM and heart failure with preserved ejection fraction (HFpEF), a well-examined association. Underlying this pathologic tandem are the effects that long-standing hyperglycemia has on the ability of the HFpEF heart to adequately deliver oxygen. It is believed that shortcomings in oxygen diffusion or utilization and the resulting hypoxia thereafter may play a role in underlying the clinical sequelae of patients with T2DM and HFpEF, with implications in the long-term decline of extra-cardiac tissue. Oxygen consumption is one of the most critical factors in indexing heart failure disease burden, warranting a probe into the role of SGLT2i on oxygen utility in HFpEF and T2DM. We investigated the role of oxygen flux in the patient with T2DM and HFpEF extending beyond the heart with focuses on cellular metabolism, perivascular fibrosis with endothelial dysfunction, hematologic changes, and renal effects with neurohormonal considerations in the patient with HFpEF and T2DM. Moreover, we give a commentary on potential therapeutic targets of these components with SGLT2i to gain insight into disease burden amelioration in patients with HFpEF and T2DM.
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17
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Vachiéry JL, Tedford RJ, Rosenkranz S, Palazzini M, Lang I, Guazzi M, Coghlan G, Chazova I, De Marco T. Pulmonary hypertension due to left heart disease. Eur Respir J 2019; 53:13993003.01897-2018. [PMID: 30545974 PMCID: PMC6351334 DOI: 10.1183/13993003.01897-2018] [Citation(s) in RCA: 356] [Impact Index Per Article: 71.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 12/22/2022]
Abstract
Pulmonary hypertension (PH) is frequent in left heart disease (LHD), as a consequence of the underlying condition. Significant advances have occurred over the past 5 years since the 5th World Symposium on Pulmonary Hypertension in 2013, leading to a better understanding of PH-LHD, challenges and gaps in evidence. PH in heart failure with preserved ejection fraction represents the most complex situation, as it may be misdiagnosed with group 1 PH. Based on the latest evidence, we propose a new haemodynamic definition for PH due to LHD and a three-step pragmatic approach to differential diagnosis. This includes the identification of a specific “left heart” phenotype and a non-invasive probability of PH-LHD. Invasive confirmation of PH-LHD is based on the accurate measurement of pulmonary arterial wedge pressure and, in patients with high probability, provocative testing to clarify the diagnosis. Finally, recent clinical trials did not demonstrate a benefit in treating PH due to LHD with pulmonary arterial hypertension-approved therapies. State of the art and research perspectives in pulmonary hypertension due to left heart disease including diagnostic and treatment insightshttp://ow.ly/vr0I30md6KC
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Affiliation(s)
- Jean-Luc Vachiéry
- Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Ryan J Tedford
- Division of Cardiology, Dept of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, Dept of Cardiology, Heart Center at the University of Cologne and Cologne Cardiovascular Research Center (CCRC), University of Cologne, Cologne, Germany
| | | | - Irene Lang
- Dept of Cardiology, AKH-Vienna, Medical University of Vienna, Vienna, Austria
| | - Marco Guazzi
- Dept of Biomedical Sciences for Health, University of Milan and Dept of Cardiology University, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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18
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Lai YC, Wang L, Gladwin MT. Insights into the pulmonary vascular complications of heart failure with preserved ejection fraction. J Physiol 2018; 597:1143-1156. [PMID: 30549058 DOI: 10.1113/jp275858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022] Open
Abstract
Pulmonary hypertension in the setting of heart failure with preserved ejection fraction (PH-HFpEF) is a growing public health problem that is increasing in prevalence. While PH-HFpEF is defined by a high mean pulmonary artery pressure, high left ventricular end-diastolic pressure and a normal ejection fraction, some HFpEF patients develop PH in the presence of pulmonary vascular remodelling with a high transpulmonary pressure gradient or pulmonary vascular resistance. Ageing, increased left atrial pressure and stiffness, mitral regurgitation, as well as features of metabolic syndrome, which include obesity, diabetes and hypertension, are recognized as risk factors for PH-HFpEF. Qualitative studies have documented that patients with PH-HFpEF develop more severe symptoms than those with HFpEF and are associated with more significant exercise intolerance, frequent hospitalizations, right heart failure and reduced survival. Currently, there are no effective therapies for PH-HFpEF, although a number of candidate drugs are being evaluated, including soluble guanylate cyclase stimulators, phosphodiesterase type 5 inhibitors, sodium nitrite and endothelin receptor antagonists. In this review we attempt to provide an updated overview of recent findings pertaining to the pulmonary vascular complications in HFpEF in terms of clinical definitions, epidemiology and pathophysiology. Mechanisms leading to pulmonary vascular remodelling in HFpEF, a summary of pre-clinical models of HFpEF and PH-HFpEF, and new candidate therapeutic strategies for the treatment of PH-HFpEF are summarized.
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Affiliation(s)
- Yen-Chun Lai
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Longfei Wang
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Berthelot E, Bauer F, Eicher JC, Flécher E, Gellen B, Guihaire J, Guijarro D, Roul G, Salvat M, Tribouilloy C, Zores F, Lamblin N, de Groote P, Damy T. Pulmonary hypertension in chronic heart failure: definitions, advances, and unanswered issues. ESC Heart Fail 2018; 5:755-763. [PMID: 30030912 PMCID: PMC6165943 DOI: 10.1002/ehf2.12316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/30/2018] [Indexed: 12/05/2022] Open
Abstract
Pulmonary hypertension (PH) is a common and severe complication of heart failure (HF). Consequently, HF is the leading cause of PH. For many years, specialists have attempted to better understand the pathophysiology of PH in HF, to define its prevalence and its impact on prognosis in order to improve the therapeutic management of these patients. Nowadays, despite the recent guidelines published on the subject, several points remain unclear or debated, and until now, no study has demonstrated the efficacy of any treatment. The aim of this review is to report the evolution of the concepts on post‐capillary PH (diagnosis, prevalence, prognosis, and therapeutics). The main issues are raised, focusing especially on the link between structural alterations and haemodynamic abnormalities, to discuss the possible reasons for treatment failures and future potential targets.
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Affiliation(s)
- Emmanuelle Berthelot
- University of Paris Sud, Le Kremlin-Bicêtre, France.,Service de Cardiologie, Pôle Thorax, Hôpital Bicêtre, AP-HP, 78 rue du Général Leclerc, 94275, Le Kremlin-Bicêtre Cedex, France
| | - Fabrice Bauer
- Department of Cardiology, Inserm U1096, Rouen University Hospital, 76031, Rouen, France
| | - Jean-Christophe Eicher
- Department of Cardiology, Dijon University Hospital, 14 rue Paul Gaffarel, 21000, Dijon, France
| | - Erwan Flécher
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital, Rennes, France.,Research Unit, Inserm U1099, University of Rennes 1, Rennes, France
| | - Barnabas Gellen
- ELSAN, Polyclinique de Poitiers, 1 rue de la Providence, 86035, Poitiers Cedex, France
| | - Julien Guihaire
- Cardiothoracic Surgery, Marie Lannelongue Hospital I, University of Paris Sud, 133 avenue de la résistance, 92350, Le Plessis Robinson, France
| | - Damien Guijarro
- Institut Cardio-Vasculaire, Groupement Hospitalier Mutualiste de Grenoble, Grenoble, France
| | - Gérald Roul
- Faculté de Médecine, Université de Strasbourg, 4 rue Kirschleger, 67085, Strasbourg Cedex, France
| | - Muriel Salvat
- Pôle thorax et vaisseaux, CHU Grenoble Alpes, La Tronche, France
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France.,Inserm U-1088, Jules Verne University of Picardie, Amiens, France
| | | | - Nicolas Lamblin
- University of Lille, Service de CHU Lille, Institut Pasteur de Lille, Inserm U1167, F-59000, Lille, France
| | - Pascal de Groote
- CHU Lille, Service de Cardiologie, F-59000, Lille, France.,Inserm U1167, Institut Pasteur de Lille, F-59000, Lille, France
| | - Thibaud Damy
- Henry Mondor Hospital, Department of Cardiology, Heart Failure and Amyloidosis Unit, Inserm/UPEC: U955, GRC Amyloid Research Institute, 51 Avenue Maréchal de Lattre de Tassigny, 94000, Créteil, France
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20
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Hauptman PJ. The Importance of Using Correct Terms. J Card Fail 2018; 24:347-348. [DOI: 10.1016/j.cardfail.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Gorter TM, Streng KW, van Melle JP, Rienstra M, Dickinson MG, Lam CSP, Hummel YM, Voors AA, Hoendermis ES, van Veldhuisen DJ. Diabetes Mellitus and Right Ventricular Dysfunction in Heart Failure With Preserved Ejection Fraction. Am J Cardiol 2018; 121:621-627. [PMID: 29307460 DOI: 10.1016/j.amjcard.2017.11.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/16/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus is associated with left-sided myocardial remodeling in heart failure with preserved ejection fraction (HFpEF). Little is known about the impact of diabetes mellitus on right ventricular (RV) function in HFpEF. We therefore studied the relation between diabetes mellitus and RV dysfunction in HFpEF. We have examined patients with HFpEF who underwent simultaneous right-sided cardiac catheterization and echocardiography. RV systolic function was assessed using multiple established echocardiographic parameters, and systolic dysfunction was present if ≥2 parameters were outside the normal range. RV diastolic function was assessed using the peak diastolic tissue velocity of the lateral tricuspid annulus (RV e') and was present if <8.0 cm/s. Diabetes mellitus was defined as a documented history of diabetes, a fasting glucose level of ≥7.0 mmol/L, a positive glucose intolerance test result, or a glycated hemoglobin level of ≥6.5%. A total of 91 patients were studied (mean age 74 ± 9 years, 69% women). A total of 37% had RV systolic dysfunction and 23% RV diastolic dysfunction. Thirty-seven percent of the patients had type 2 diabetes mellitus. These patients had higher pulmonary artery pressure (34 mm Hg vs 29 mm Hg, p = 0.004), more RV systolic dysfunction (57% vs 29%, p = 0.009), more RV diastolic dysfunction (46% vs 12%, p = 0.001), and lower RV e' (8.7 cm/s vs 11.5 cm/s, p = 0.006). The presence of diabetes mellitus was independently associated with RV systolic dysfunction (odds ratio 2.84, 95% confidence interval 1.09 to 7.40, p = 0.03) and with RV diastolic dysfunction (odds ratio 4.33, 95% confidence interval 1.25 to 15.07, p = 0.02), after adjustment for age, gender, and pulmonary pressures. In conclusion, diabetes mellitus is strongly associated with RV systolic and diastolic dysfunctions in patients with HFpEF, independent of RV afterload.
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Affiliation(s)
- Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Koen W Streng
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael G Dickinson
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carolyn S P Lam
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Cardiology, National Heart Center Singapore, Singapore Duke-NUS Graduate Medical School, Singapore
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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22
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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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