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Zeder K, Douschan P, Foris V, Sassmann T, Maron BA, Olschewski H, Kovacs G. The prognostic relevance of exercise pulmonary hypertension in cardiac and pulmonary diseases. Curr Opin Pulm Med 2024; 30:451-458. [PMID: 38958564 DOI: 10.1097/mcp.0000000000001096] [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: 07/04/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of the prognostic implications of exPH in patients with various common cardiac and pulmonary diseases. RECENT FINDINGS Exercise pulmonary hypertension (exPH) has been recently re-introduced in the current European Society of Cardiology/European Respiratory Society pulmonary hypertension guidelines. Accordingly, exPH is defined as a mean pulmonary arterial pressure (mPAP)/cardiac output ( CO ) slope greater than 3 mmHg/l/min. Key considerations for this re-introduction included increasing understanding on normal pulmonary hemodynamics during exercise and the broadly available evidence on the association of an abnormal mPAP/ CO slope with poor survival in the general population and in different disease entities. SUMMARY Exercise (patho-)physiology has opened a new field for clinical research facilitating recognition of cardiovascular and pulmonary vascular diseases in an early stage. Such early recognition with significant prognostic and possibly therapeutic relevance, but being undetectable at rest, makes exercise pulmonary hemodynamics particularly interesting for common diseases, such as valvular heart disease, left heart disease, and chronic pulmonary disease.
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Affiliation(s)
- Katarina Zeder
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore
- University of Maryland-Institute for Health Computing, Bethesda, Maryland, USA
| | - Philipp Douschan
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vasile Foris
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Teresa Sassmann
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Bradley A Maron
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore
- University of Maryland-Institute for Health Computing, Bethesda, Maryland, USA
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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2
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Zeder K, Brittain E, Kovacs G, Maron BA. The Management of Mild Pulmonary Hypertension in Clinical Practice. Ann Am Thorac Soc 2024; 21:1115-1123. [PMID: 38747696 PMCID: PMC11298986 DOI: 10.1513/annalsats.202312-1079fr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/15/2024] [Indexed: 08/02/2024] Open
Abstract
The definition of pulmonary hypertension (PH) has been revised recently, with the mean pulmonary artery pressure (mPAP) threshold (assessed by right heart catheterization) reduced from ⩾25 mm Hg to >20 mm Hg. This change reflects the mPAP upper limit of normal and a lower limit that is independently associated with adverse outcomes. To improve the specificity of diagnosing pathogenic increases in mPAP, however, a diagnosis of precapillary PH now also includes pulmonary vascular resistance >2.0 Wood units (WU) (lowered from >3.0 WU). These changes are positioned to capture approximately 55% more patients with PH. Because all clinical trials showing a benefit of pulmonary vasodilator therapy in precapillary PH used the classical hemodynamic definition, the approach to the diagnosis and management of patients with mild PH (i.e., mPAP 21-24 mm Hg and pulmonary vascular resistance 2-3 WU) requires particular consideration. Here, we use a question/answer format to discuss key areas in the management of mild PH, including practical information tailored to clinicians without training in PH.
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Affiliation(s)
- Katarina Zeder
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
| | - Evan Brittain
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gabor Kovacs
- Department of Pulmonology, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, Maryland; and
- The University of Maryland-Institute for Health Computing, Bethesda, Maryland
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3
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Mathai SC. Pulmonary Hypertension Associated with Connective Tissue Disease. Rheum Dis Clin North Am 2024; 50:359-379. [PMID: 38942575 DOI: 10.1016/j.rdc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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4
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Gerges C, Beurnier A, Jaïs X, Hervé P, Lau EMT, Girerd B, Günther S, Bouchachi A, Jevnikar M, Boucly A, Bogaard HJ, Simonneau G, Sitbon O, Savale L, Chemla D, Humbert M, Montani D. Exercise Hemodynamics Predict Pulmonary Arterial Hypertension in BMPR2 Mutation Carriers. Chest 2024:S0012-3692(24)04839-6. [PMID: 39059577 DOI: 10.1016/j.chest.2024.06.3808] [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: 03/08/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Exercise hemodynamics are recommended for early detection of pulmonary arterial hypertension (PAH) and have been suggested to be predictive of future development of PAH in high-risk populations such as BMPR2 mutation carriers. However, the optimal exercise hemodynamic screening parameter remains to be determined. Recent data suggest that pulmonary vascular distensibility coefficient (α) may serve as a useful parameter for early detection of PAH. RESEARCH QUESTION What is the value of exercise hemodynamics, including α, for predicting the occurrence of PAH during long-term follow-up in BMPR2 mutation carriers? STUDY DESIGN AND METHODS Fifty-two asymptomatic BMPR2 mutation carriers who underwent symptom-limited exercise hemodynamic assessment were followed up for a median of 10 years. The impact of hemodynamics at rest and exercise, presence of exercise pulmonary hypertension, and α on occurrence of PAH during long-term follow-up were assessed. RESULTS During long-term follow-up, five patients demonstrated PAH. Patients who demonstrated PAH showed a significantly lower α (0.8 ± 0.4%/mm Hg) than patients without PAH (1.8 ± 0.8%/mm Hg; P = .008). The only hemodynamic parameter that predicted the occurrence of PAH during long-term follow-up at regression analysis was α. Receiver operating characteristic analysis showed that α ≤ 1.5%/mm Hg predicted PAH occurrence with a specificity of 75% and sensitivity of 100%. INTERPRETATION Before development of PAH in BMPR2 mutation carriers, α is reduced markedly and may serve as a useful parameter in the setting of early disease detection. Given the low event rate, caution is warranted in interpreting these results, highlighting the need for validation studies.
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Affiliation(s)
- Christian Gerges
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria; School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Antoine Beurnier
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Xavier Jaïs
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Philippe Hervé
- INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France; Service de Chirurgie Thoracique, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Edmund M T Lau
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Barbara Girerd
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Sven Günther
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, Paris, France
| | - Amir Bouchachi
- Service de Physiologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; Service de Cardiologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | - Mitja Jevnikar
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Athénaïs Boucly
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Gérald Simonneau
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Olivier Sitbon
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Laurent Savale
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Denis Chemla
- Service de Physiologie, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France
| | - David Montani
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, Paris, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, Paris, France; INSERM UMRS 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, Paris, France.
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Kanazawa Y, Goda A, Mohri T, Takeuchi S, Takeuchi K, Kikuchi H, Inami T, Soejima K, Kohno T. Exercise pulmonary hypertension in patients with systemic sclerosis based on updated guidelines. Sci Rep 2024; 14:13358. [PMID: 38858443 PMCID: PMC11164881 DOI: 10.1038/s41598-024-63823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024] Open
Abstract
Recent European guidelines have introduced the concept of exercise pulmonary hypertension (ex-PH). However, the clinical characteristics of ex-PH in systemic sclerosis (SSc) remains unknown. We aimed to investigate the characteristics of exercise pulmonary hypertension (ex-PH) in patients with systemic sclerosis (SSc), which are unknown. We retrospectively examined 77 patients with SSc who underwent symptom-limited exercise testing using a cycle ergometer with right heart catheterization at our hospital. Nineteen patients with postcapillary PH were excluded. Fifty-eight patients (median age, 63 years; 55 women) were divided into the overt-PH (n = 18, mean pulmonary arterial pressure [PAP] > 20 mmHg and pulmonary vascular resistance > 2 Wood units at rest), ex-PH (n = 19, mean PAP/cardiac output slope > 3), and non-PH (n = 21) groups. Exercise tolerance and echocardiography results were compared among the groups. Peak oxygen consumption was high in the non-PH group, intermediate in the ex-PH group, and low in the overt-PH group (14.5 vs. 13.0 vs. 12.5 mL/kg/min, p = 0.043), and the minute ventilation/peak carbon dioxide production slope was also intermediate in the ex-PH group (32.2 vs. 32.4 vs. 43.0, p = 0.003). The tricuspid annular plane systolic excursion/systolic PAP ratio decreased from non-PH to ex-PH to overt-PH (0.73 vs. 0.69 vs. 0.55 mm/mmHg, p = 0.018). In patients with SSc, exercise PH may represent an intermediate condition between not having PH and overt PH, according to the new guidelines.
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Affiliation(s)
- Yu Kanazawa
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
| | - Takato Mohri
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Kaori Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hanako Kikuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takumi Inami
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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Olschewski H, Zeder K, Douschan P, Sassmann T, Foris V, Olschewski A, Kovacs G. Let's Talk About Respiratory Swings! Am J Respir Crit Care Med 2023; 208:1338-1340. [PMID: 37871311 PMCID: PMC10765390 DOI: 10.1164/rccm.202309-1637le] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023] Open
Affiliation(s)
- Horst Olschewski
- Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Katarina Zeder
- Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philipp Douschan
- Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Giessen, Germany; and
| | - Teresa Sassmann
- Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Vasile Foris
- Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Andrea Olschewski
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Experimental Anesthesiology, Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gabor Kovacs
- Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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7
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Lechartier B, Kularatne M, Jaïs X, Humbert M, Montani D. Updated Hemodynamic Definition and Classification of Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:721-727. [PMID: 37595614 DOI: 10.1055/s-0043-1770115] [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: 08/20/2023]
Abstract
Pulmonary hypertension (PH) is a pathophysiological manifestation of a heterogeneous group of diseases characterized by abnormally elevated pulmonary arterial pressures diagnosed on right heart catheterization. The 2022 European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines for the diagnosis and treatment of PH provides a new hemodynamic definition to define PH by lowering the threshold of the mean pulmonary artery pressure (mPAP) to 20 mm Hg. Precapillary PH is thus now defined as a mPAP >20 mm Hg together with a normal pulmonary artery wedge pressure (<15 mm Hg) and an increased pulmonary vascular resistance (>2 Wood Units). The ESC/ERS 2022 Guidelines also introduce a revised clinical classification of PH while retaining its previous distinction between the five groups according to the underlying pathophysiology.
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Affiliation(s)
- Benoit Lechartier
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Respiratory Division, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Mithum Kularatne
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Canada
| | - Xavier Jaïs
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Marc Humbert
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - David Montani
- Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies," Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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8
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [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: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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9
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Douschan P, Egenlauf B, Gall H, Grünig E, Hager A, Heberling M, Koehler T, Olschewski H, Seyfarth HJ, Yogeswaran A, Ulrich S, Kovacs G. [New definition and classification of pulmonary hypertension]. Pneumologie 2023; 77:854-861. [PMID: 37963475 DOI: 10.1055/a-2145-4648] [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: 11/16/2023]
Abstract
In the recent ESC/ERS guidelines on the diagnosis and management of pulmonary hypertension (PH) several important changes have been made in respect of the definition and classification of PH.The mPAP cut-off for defining PH was lowered. PH is now defined by an mPAP > 20 mmHg assessed by right heart catheterization. Moreover, the PVR threshold for defining precapillary PH was lowered. Precapillary PH is now defined by a PVR > 2 WU and a pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg. Furthermore, the increasing evidence for the clinical relevance of pulmonary exercise hemodynamics led to the reintroduction of exercise pulmonary hypertension (EPH) 1. EPH is characterized by a mPAP/CO-slope > 3 mmHg/L/min during exercise testing. In the classification of PH five groups are distinguished: Pulmonary arterial hypertension (group 1), PH associated with left heart disease (group 2), PH associated with lung diseases and/or hypoxia (Group 3), PH associated with pulmonary artery obstructions (group 4) and PH with unclear and/or multi-factorial mechanisms (group 5).In the following guideline-translation we focus on novel aspects regarding the definition and classification of PH and to provide additional background information.
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Affiliation(s)
- Philipp Douschan
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Benjamin Egenlauf
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg, Germany
- Abteilung für Pneumologie und Beatmungsmedizin, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Henning Gall
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Ekkehard Grünig
- Zentrum für Pulmonale Hypertonie, Thoraxklinik am Universitätsklinikum Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Alfred Hager
- Department for Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Melanie Heberling
- Universitätsklinikum Carl Gustav Carus an der TU Dresden, Med. Klinik I, Bereich Pneumologie, Dresden, Deutschland
| | - Thomas Koehler
- Universitätsklinikum Freiburg, Department Innere Medizin, Klinik für Pneumologie, Freiburg, Deutschland
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Hans-Jürgen Seyfarth
- Department of Pneumology, Medical Clinic II, University Hospital of Leipzig, Leipzig, Germany
| | - Athiththan Yogeswaran
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Institute for Lung Health (ILH), Cardio-Pulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Silvia Ulrich
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz and Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
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10
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Boucly A, Gerges C, Savale L, Jaïs X, Jevnikar M, Montani D, Sitbon O, Humbert M. Pulmonary arterial hypertension. Presse Med 2023; 52:104168. [PMID: 37516248 DOI: 10.1016/j.lpm.2023.104168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre. Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways. The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated. Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.
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Affiliation(s)
- Athénaïs Boucly
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France; National Heart and Lung Institute, Imperial College London, London, UK.
| | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Laurent Savale
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, Faculé de Médicine, Le Kremlin-Bicêtre, France; Service de Pneumologie et Soins Intensifs Respiratoires, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMRS-999, Le Kremlin-Bicêtre, France
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11
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Škafar M, Ambrožič J, Toplišek J, Cvijić M. Role of Exercise Stress Echocardiography in Pulmonary Hypertension. Life (Basel) 2023; 13:1385. [PMID: 37374168 PMCID: PMC10302645 DOI: 10.3390/life13061385] [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: 05/01/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Resting and exercise right heart catheterisation is the gold standard method to diagnose and differentiate types of pulmonary hypertension (PH). As it carries technical challenges, the question arises if non-invasive exercise stress echocardiography may be used as an alternative. Exercise echocardiography can unmask exercise PH, detect the early stages of left ventricular diastolic dysfunction, and, therefore, differentiate between pre- and post-capillary PH. Regardless of the underlying aetiology, a developed PH is associated with increased mortality. Parameters of overt right ventricle (RV) dysfunction, including RV dilation, reduced RV ejection fraction, and elevated right-sided filling pressures, are detectable with resting echocardiography and are associated with worse outcome. However, these measures all fail to identify occult RV dysfunction. Echocardiographic measures of RV contractile reserve during exercise echocardiography are very promising and provide incremental prognostic information on clinical outcome. In this paper, we review pulmonary haemodynamic response to exercise, briefly describe the modalities for assessing pulmonary haemodynamics, and discuss in depth the contemporary key clinical application of exercise stress echocardiography in patients with PH.
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Affiliation(s)
- Mojca Škafar
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Jana Ambrožič
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
| | - Janez Toplišek
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
| | - Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; (M.Š.); (J.A.); (J.T.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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12
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 501] [Impact Index Per Article: 501.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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13
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Zeder K, Olschewski H, Kovacs G. Updated definition of exercise pulmonary hypertension. Breathe (Sheff) 2022; 18:220232. [PMID: 36865934 PMCID: PMC9973500 DOI: 10.1183/20734735.0232-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/02/2022] [Indexed: 02/16/2023] Open
Abstract
In the recently published European Society of Cardiology/European Respiratory Society guidelines on the diagnosis and treatment of pulmonary hypertension (PH) the haemodynamic definitions of PH were updated and a new definition for exercise PH was introduced. Accordingly, exercise PH is characterised by a mean pulmonary arterial pressure/cardiac output (CO) slope >3 Wood units (WU) from rest to exercise. This threshold is supported by several studies demonstrating prognostic and diagnostic relevance of exercise haemodynamics in various patient cohorts. From a differential diagnostic point of view, an elevated pulmonary arterial wedge pressure/CO slope >2 WU may be suitable to identify post-capillary causes of exercise PH. Right heart catheterisation remains the gold standard to assess pulmonary haemodynamics both at rest and exercise. In this review, we discuss the evidence that led to the reintroduction of exercise PH in the PH definitions.
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Affiliation(s)
- Katarina Zeder
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Horst Olschewski
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Gabor Kovacs
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria,Corresponding author: Gabor Kovacs ()
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14
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Montani D, Jutant EM, Simonneau G, Humbert M. Nouvelles définitions et classification de l’hypertension pulmonaire. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1152] [Impact Index Per Article: 576.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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16
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Sassmann T, Douschan P, Foris V, Tröster N, Zeder K, Brcic L, Tornyos A, Bachmaier G, Fuchsjäger M, Olschewski H, Kovacs G. Abnormal pulmonary hemodynamics during exercise is associated with exercise capacity in COPD. Respir Res 2022; 23:331. [PMID: 36482405 PMCID: PMC9733173 DOI: 10.1186/s12931-022-02238-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/03/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a frequent complication in COPD and it is associated with decreased exercise capacity and poor prognosis. We hypothesized that even in COPD patients without significant PH at rest, abnormal pulmonary hemodynamics during exercise affect exercise capacity. METHODS Consecutive COPD patients with clinically indicated right heart catheterization and resting mean pulmonary arterial pressure (mPAP) < 25 mmHg and age- and sex-matched controls with the same limits of pulmonary hemodynamics but no chronic lung disease who underwent clinical work-up including invasive hemodynamic assessment during exercise, were retrospectively analyzed. Chi-square tests were used to evaluate differences between groups for categorical data and Fisher's exact test or Mann-Whitney-U-tests for continuous variables. Associations were analyzed with Spearman rank correlation tests. RESULTS We included n = 26 COPD patients (female/male: 16/10, 66 ± 11 yr, FEV1: 56 ± 25%predicted) and n = 26 matched controls (FEV1: 96 ± 22%predicted). At rest, COPD patients presented with slightly increased mPAP (21 (18-23) vs. 17 (14-20) mmHg, p = 0.022), and pulmonary vascular resistance (PVR) [2.5 (1.9-3.0) vs. 1.9 (1.5-2.4) WU, p = 0.020] as compared to controls. During exercise, COPD patients reached significantly higher mPAP [47 (40-52) vs. 38 (32-44) mmHg, p = 0.015] and PVR [3.1 (2.2-3.7) vs. 1.7 (1.1-2.9) WU, p = 0.028] values despite lower peak exercise level [50 (50-75) vs. 100 (75-125) Watt, p = 0.002]. The mPAP/cardiac output slope was increased in COPD vs. controls [6.9 (5.5-10.9) vs. 3.7 (2.4-7.4) mmHg/L/min, p = 0.007] and negatively correlated with both peak oxygen uptake (r = - 0.46, p = 0.007) and 6-min walk distance (r = - 0.46, p = 0.001). CONCLUSION Even in the absence of significant PH at rest, COPD patients reveal characteristic abnormalities in pulmonary hemodynamics during exercise, which may represent an important exercise-limiting factor.
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Affiliation(s)
- Teresa Sassmann
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria ,grid.489038.e0000 0004 9291 7536Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010 Graz, Austria
| | - Philipp Douschan
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria ,grid.489038.e0000 0004 9291 7536Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010 Graz, Austria
| | - Vasile Foris
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria ,grid.489038.e0000 0004 9291 7536Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010 Graz, Austria
| | - Natascha Tröster
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Katarina Zeder
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria ,grid.489038.e0000 0004 9291 7536Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010 Graz, Austria
| | - Luka Brcic
- grid.11598.340000 0000 8988 2476Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Adrienn Tornyos
- grid.11598.340000 0000 8988 2476Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Gerhard Bachmaier
- grid.11598.340000 0000 8988 2476Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Michael Fuchsjäger
- grid.11598.340000 0000 8988 2476Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Horst Olschewski
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria ,grid.489038.e0000 0004 9291 7536Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010 Graz, Austria
| | - Gabor Kovacs
- grid.11598.340000 0000 8988 2476Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria ,grid.489038.e0000 0004 9291 7536Ludwig Boltzmann Institute for Lung Vascular Research, Stiftingtalstrasse 24, 8010 Graz, Austria
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17
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Ewert R, Stubbe B, Heine A, Desole S, Habedank D, Knaack C, Hortien F, Opitz CF. [Invasive Cardiopulmonary Exercise Testing: A Review]. Pneumologie 2021; 76:98-111. [PMID: 34844269 DOI: 10.1055/a-1651-7450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.
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Affiliation(s)
- Ralf Ewert
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Beate Stubbe
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Alexander Heine
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Susanna Desole
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Dirk Habedank
- DRK Kliniken Berlin Köpenick, Medizinische Klinik Kardiologie, Berlin
| | - Christine Knaack
- Universitätsmedizin Greifswald, Klinik für Innere Medizin C, Greifswald
| | - Franziska Hortien
- Universitätsmedizin Greifswald, Klinik für Innere Medizin B, Bereich Pneumologie und Weaningzentrum, Greifswald
| | - Christian F Opitz
- DRK Kliniken Berlin Westend, Klinik für Innere Medizin, Schwerpunkt Kardiologie, Berlin
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18
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Abstract
Pulmonary hypertension (PH), a syndrome characterized by elevated pulmonary pressures, commonly complicates connective tissue disease (CTD) and is associated with increased morbidity and mortality. The incidence of PH varies widely between CTDs; patients with systemic sclerosis are most likely to develop PH. Several different types of PH can present in CTD, including PH related to left heart disease and respiratory disease. Importantly, CTD patients are at risk for developing pulmonary arterial hypertension, a rare form of PH that is associated with high morbidity and mortality. Future therapies targeting pulmonary vascular remodeling may improve outcomes for patients with this devastating disease.
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Affiliation(s)
- Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Room 540, Baltimore, MD 21205, USA.
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19
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Haque A, Kiely DG, Kovacs G, Thompson AAR, Condliffe R. Pulmonary hypertension phenotypes in patients with systemic sclerosis. Eur Respir Rev 2021; 30:30/161/210053. [PMID: 34407977 DOI: 10.1183/16000617.0053-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/04/2021] [Indexed: 01/05/2023] Open
Abstract
Pulmonary hypertension (PH) commonly affects patients with systemic sclerosis (SSc) and is associated with significant morbidity and increased mortality. PH is a heterogenous condition and several different forms can be associated with SSc, including pulmonary arterial hypertension (PAH) resulting from a pulmonary arterial vasculopathy, PH due to left heart disease and PH due to interstitial lung disease. The incidence of pulmonary veno-occlusive disease is also increased. Accurate and early diagnosis to allow optimal treatment is, therefore, essential. Recent changes to diagnostic haemodynamic criteria at the 6th World Symposium on Pulmonary Hypertension have resulted in therapeutic uncertainty regarding patients with borderline pulmonary haemodynamics. Furthermore, the optimal pulmonary vascular resistance threshold for diagnosing PAH and the role of exercise in identifying early disease require further elucidation. In this article we review the epidemiology, diagnosis, outcomes and treatment of the spectrum of pulmonary vascular phenotypes associated with SSc.
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Affiliation(s)
- Ashraful Haque
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Dept of Rheumatology, Royal Hallamshire Hospital, Sheffield, UK.,Both authors contributed equally
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Gabor Kovacs
- Medical University of Graz, Graz, Austria.,Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK .,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Both authors contributed equally
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20
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Ulrich S, Mathai SC. Performance Under Pressure: The Relevance of Pulmonary Vascular Response to Exercise Challenge in Scleroderma. Chest 2021; 159:481-483. [PMID: 33563435 DOI: 10.1016/j.chest.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland.
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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21
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Mukherjee M, Mercurio V, Hsu S, Mayer SA, Mathai SC, Hummers LK, Kass DA, Hassoun PM, Wigley FM, Tedford RJ, Shah AA. Assessment of right ventricular reserve utilizing exercise provocation in systemic sclerosis. Int J Cardiovasc Imaging 2021; 37:2137-2147. [PMID: 33860914 DOI: 10.1007/s10554-021-02237-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/03/2021] [Indexed: 01/28/2023]
Abstract
Right ventricular (RV) capacity to adapt to increased afterload is the main determinant of outcome in pulmonary hypertension, a common morbidity seen in systemic sclerosis (SSc). We hypothesized that supine bicycle echocardiography (SBE), coupled with RV longitudinal systolic strain (RVLSS), improves detection of limitations in RV reserve in SSc. 56 SSc patients were prospectively studied during SBE with RV functional parameters compared at rest and peak stress. We further dichotomized patients based on resting RV systolic pressure (RVSP) to determine the effects of load on contractile response. Our pooled cohort analysis revealed reduced global RVLSS at rest (-16.2 ± 3.9%) with normal basal contractility (-25.6 ± 7.7%) and relative hypokinesis of the midventricular (-14.1 ± 6.0%) and apical (-8.9 ± 5.1%) segments. With exercise, global RVLSS increased significantly (p = 0.0005), however despite normal basal contractility at rest, there was no further augmentation with exercise. Mid and apical RVLSS increased with exercise suggestive of RV contractile reserve. In patients with resting RVSP < 35 mmHg, global and segmental RVLSS increased with exercise. In patients with resting RVSP ≥ 35 mmHg, global and segmental RVLSS did not increase with exercise and there was evidence of exertional RV dilation. Exercise provocation in conjunction with RVLSS identified differential regional contractile response to exercise in SSc patients. We further demonstrate the effect of increased loading conditions on RV contractile response exercise. These findings suggest subclinical impairments in RV reserve in SSc that may be missed by resting noninvasive 2DE-based assessments alone.
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Affiliation(s)
- Monica Mukherjee
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.
| | - Valentina Mercurio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Steven Hsu
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA
| | - Susan A Mayer
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.,Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - David A Kass
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fredrick M Wigley
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ryan J Tedford
- Division of Cardiology, Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.,Division of Cardiology, Medical University South Carolina, Charleston, SC, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
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